---
type: vaccine
category: travel
person: Yanxin Lu
date: 2021-12-16
source: 疫苗接种声明书_lu.pdf
---

# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Lu Yanxin

## Declarant Information

| Field (中文) | Field (English) | Value |
|------------|-----------------|-------|
| 声明人姓名 | Name | 陆彦忻 |
| 性别 | Gender | 男 (Male) |
| 出生日期 | Date of Birth | 1989年10月17日 |
| 护照号 | Passport No. | E93603635 |
| 电话 | Telephone | +12542241457 |
| 电邮 | Email | crac1017@gmail.com |

## Statement (声明内容)

1. 本人已接种新冠疫苗，接种详情如下 / I have received COVID-19 vaccination and the details are as follows:

| # | Field (中文) | Field (English) | Value |
|---|-----------|-----------------|-------|
| 1 | 疫苗品牌名称 | Vaccine brand name | 辉瑞 (Pfizer) |
| 2 | 接种机构名称 | Name of vaccination institution | Forum Stadium |
| 3 | 接种机构地址 | Address of vaccination institution | 3900 W Manchester Blvd, Inglewood, CA, 90305 |
| 4 | 接种机构联系方式 | Contact information | 833-540-0473 |
| 5 | 疫苗接种剂次 | Doses | 二剂次 / Two doses (checked) |

### Vaccination Dates

| Dose | Date |
|------|------|
| 第一剂 / First dose | 2021年4月15日 |
| 第二剂 / Second dose | 2021年5月6日 |

2. 本人所附疫苗接种凭证（接种卡或其它接种证明）真实无误。
I hereby declare that the attached vaccination certificate (vaccination card or other forms of certification) is true and accurate.

本人保证以上所有内容真实，并愿意承担由此引起的一切法律责任，包括但不限于因虚报、瞒报导致被限制去中国旅行或被追究法律责任等后果。
I hereby declare that the information provided above is true, and I shall bear all legal responsibilities arising therefrom, including but not limited to restricted travel to China, punishment by law, or other consequences in the case of partial or false disclosures.

**声明人签名 / Signature:** (signed)
**日期 / Date:** 2021年12月16日