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ENTRY-EXIT INSPECTION AND QUARANTINE THE PEOPLE’S REPUBLIC OF CHINA HEALTH AND QUARANTINE DECLARATION FORM ON ENTRY Name: Shirley_Booth Sex: Male √ Female Birth Date: 1959_yy_02_mm Nationality(Region): American Time of Arrival: 17:20_hh_ Place of arrival: Shenzhen From(Country/Region): USA Passport No.: CA5728019 Vehicle/ Ship/Flight No.: Flight_UA_3625 Seat No.: 16E Destination: Changsha,_Hunan 1.Please list the countries and cities(towns) that you have visited in the past 4 weeks: New_York,_Paris,_Tokyo_and_Hong_Kong 2.The contact address and telephone number in the next 14 days: Changsha_Friendship_Hotel 3.Please mark “√” before the items of following symptoms or illness if you have any now. Fever Cough Other disease Shortness of breath Difficulty breathing 4.Have you had close contact with any probable or suspected H1N1 case in the past 14 days? Yes √ No 5.Please mark “√”before the items of following articles if you bring any of them. Animal Animal products Plant Plant products √ Biological products Waste and used clothing Soil I hereby declare that all the information given above is true and correct. Date: April_16,_2009 Signature: Shirley_Booth Note: 1. For the health of all, please give true and correct information; 2. You will be sued according to related laws if you give the false information; 3. No entry shall be allowed without the declaration; 4. Body temperature: 37°C |
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