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