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obsidian-yanxin/documents/travel/china_2021/疫苗接种声明书_jiang.md
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vaccine travel Xuewei Jiang 2021-12-16 疫苗接种声明书_jiang.pdf

新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Jiang Xuewei

Declarant Information

Field (中文) Field (English) Value
声明人姓名 Name 姜薛伟
性别 Gender 女 (Female)
出生日期 Date of Birth 1993年3月13日
护照号 Passport No. EJ4954380
电话 Telephone +12542149350
电邮 Email xueweijiang0313@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 University of Southern California
3 接种机构地址 Address of vaccination institution 3701 Flower St, Los Angeles, CA 90007
4 接种机构联系方式 Contact information 213-740-9355
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6日
第二剂 / Second dose 2021年4月27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