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

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

This is a scanned/photographed copy of the signed declaration form. The PDF version (疫苗接种声明书_lu.pdf) contains the same content. This JPG shows the completed form with handwritten signature.

## Declarant Information

| Field | Value |
|-------|-------|
| Name (声明人姓名) | 陆彦忻 |
| Gender (性别) | 男 (Male) |
| Date of Birth (出生日期) | 1989年10月17日 |
| Passport No. (护照号) | E93603635 |
| Telephone (电话) | +12542241457 |
| Email (电邮) | crac1017@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) | Forum Stadium |
| Address (接种机构地址) | 3900 W Manchester Blvd, Inglewood, CA, 90305 |
| Contact (接种机构联系方式) | 833-540-0473 |
| Doses (剂次) | Two doses (二剂次) checked |
| First dose date (第一剂接种日期) | 2021年4月15日 |
| Second dose date (第二剂接种日期) | 2021年5月6日 |

**Signature:** (handwritten signature present)
**Date:** 2021年12月16日