新冠疫苗接种声明书.pdf

新冠疫苗接种声明书 Letter of Commitment on COVID-19 Vaccination 声明人姓名Nam ：__________________ ，性别Gender ：_____ ， 出生日期Date of birth ：_________年Year_____月Month_____ 日Dat ， 护照号Passport No. ：______________ ， 电话Telephon ：________________ ，电邮Email ：_____________________ 声明内容Statement: 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： ① 疫苗品牌名称Vaccine brand nam ：________________ ② 接种机构名称Name of vaccination institution ：________________ ③ 接种机构地址（国家、省 / 州、市、街道、门牌号） Address of vaccination institution (country, province/state, city, str t, building number) ： ________________________ ④ 接种机构联系方式 ( 电话、电子邮件） Contact information of vaccination institution (telephone, email) ：____________________________ ⑤ 疫苗接种剂次及接种日期（请选择并填写） Doses and date of vaccination (please select one and fill in the blanks) ： □一剂次One dos 接种日期Date of vaccination ：_____年Year___月Month___ 日Dat □二剂次Two doses 第一剂接种日期 Date of vaccination for first dos ：____年Year___月Month___ 日Dat 第二剂接种日期 Date of vaccination for second dos ：____年Year___月Month___ 日Dat 2. 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 declar 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Signatur ：____________ _______年Year_____月Month_____ 日Dat