D ENTRY-EXIT INSPECTION AND QUARANTINE THE PEOPLE’S REPUBLIC OF CHINA HEALTH AND

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