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documents/travel/china_2021/新冠疫苗接种声明书_jiang.md Normal file
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---
type: vaccine-declaration
category: travel
person: Xuewei Jiang
date: 2021-12-16
source: 新冠疫苗接种声明书_jiang.jpg
---
# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Jiang Xuewei (Signed Copy)
This is a scanned/photographed copy of the signed declaration form. The PDF version (疫苗接种声明书_jiang.pdf) contains the same content. This JPG shows the completed form with handwritten signature.
## Declarant Information
| Field | Value |
|-------|-------|
| Name (声明人姓名) | 姜薛伟 |
| Gender (性别) | 女 (Female) |
| Date of Birth (出生日期) | 1993年3月13日 |
| Passport No. (护照号) | EJ4954380 |
| Telephone (电话) | +12542149350 |
| Email (电邮) | xueweijiang0313@gmail.com |
## Vaccination Details
| Field | Value |
|-------|-------|
| Vaccine brand name (疫苗品牌名称) | 辉瑞 (Pfizer) |
| Vaccination institution (接种机构名称) | University of Southern California |
| Address (接种机构地址) | 3701 Flower St, Los Angeles, CA 90007 |
| Contact (接种机构联系方式) | 213-740-9355 |
| Doses (剂次) | Two doses (二剂次) checked |
| First dose date (第一剂接种日期) | 2021年4月6日 |
| Second dose date (第二剂接种日期) | 2021年4月27日 |
**Signature:** (handwritten signature present)
**Date:** 2021年12月16日