To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our clients and visitors like you, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Information collected will be kept safely and any personal information will not be disclosed unless as required by law.

* Required

Today's Date: *

Temperature: *

First Name *

Last Name *

Personal Contact # (Mobile / Home #) *

Your E-mail Address* *

Purpose of Visit*

HEREBY CONFIRM THAT ALL STATEMENTS ARE TRUE AND COMPLETE*.

"By signing this form/document, I hereby acknowledge that Autohub Group of Companies, including its parent company, affiliates, subsidiaries, and related  companies, as well as their respective officers, directors, shareholders, employees, agents, and other parties with which they do business (hereinafter collectively referred to as “Company”), may use and process all personal information that I have voluntarily and knowingly provided , including those that may be sensitive or confidential as may be disclosed by me, in any transaction or  activity related to the Company for the purpose herein stated specifically for public health and safety purposes in effecting control of the COVID-19 infection. Use and processing of Personal Information includes collection, recording, listing, systematization, accumulation, storage, updating, extraction, transfer, anonymization, blocking, deletion, destruction, whether through electronic means or otherwise. I understand that by personal information is protected by RA 10173, Data Privacy Act of 2012, and that I am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.  I hereby release and forever discharge the Company, including its parent company, affiliates, subsidiaries, and related companies, as well as their respective officers, directors, shareholders, employees, agents, and other parties with which they do business, in their official corporate capacities as well as in their individual personal capacities, from any and all sums of money, or any other obligations, privilege, emolument, entitlement, and benefit arising from any and all incident, directly or indirectly related to, the use and processing of all personal and sensitive information. I likewise categorically declare that I do not have and will not institute any claim or cause of action in relation to the use and processing of personal and sensitive information by the Company."