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
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.
