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vaccine travel Yanxin Lu 2021-12-16 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
  1. 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