SELF-DECLARATION FORM JUSTIFYING TRAVEL IN ITALY FROM ABROAD

(to be delivered to the public transport carrier)

The undersigned declarant (full name) , born on (date of birth)__/ /

in (place of birth) (Province ), nationality ,
resident in (Province ), address ,
being aware of the criminal liability for misrepresentation and the counterfeiting or use of counterfeited
official documents, besides the penalties provided in article in article 2 of Decree-Law 33 of 16 may 2020;
hereby
DECLARES AS FOLLOWS, UNDER HIS/HER RESPONSIBILITY

1. he/she is aware of the measures for containing the spread of COVID-19 in force in Italy and, in particular, of
the requirements laid down in the decrees of the President of the Council of Ministers of 7 August and 7
September 2020;

2. he/she has not tested positive to COVID-19 or, if he/she tested positive to an rT PCR test carried out abroad,
that he/she has scrupulously followed the health protocols laid down by the authorities of the Country where the
test was carried out and has observed 14 days of isolation since the date in the symptoms were detected, and
he/she is longer subject to quarantine measures imposed by the local authorities;

3. he/she has entered Italy from the following foreign location , by the
following means of transport (if a private vehicle indicate the type and registration plate; if a public mean of
transport specify flight number/rail or bus service number/boat or ferry route):
;

4. over the last 14-day period, he/she has transited/stayed in the following Countries and territories:

5. the declarant fulfils one of the following conditions or requirements (it is mandatory to circle one of the following
options):

A) he/she is a crew member of a means of transport or travel staff member;

B) he/she is entering Italy from the Republic of San Marino or the Vatican City State;
C) he/she is entering Italy for work purposes, as regulated by special safety protocols approved by the
competent health authority;
D) he/she is entering Italy from one of the following Countries (and has not stayed or transited in other
countries not mentioned in this list over the last 14 days): Austria, Bulgaria, Cyprus, Croatia,
Denmark, Estonia, Finland, Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg,
Malta, Poland, Portugal, Slovakia, Slovenia, Sweden, Iceland, Liechtenstein, Norway, Switzerland,
Andorra, Principality of Monaco;
 E) he/she is entering Italy after having stayed or transited in any of the following countries over the last
14-day period: Belgium, the Czech Republic, France, the Netherlands, Spain and the United
Kingdom. In this case, the following alternative prevention measures shall apply:
a) at boarding, the obligation to submit to the carrier, and to other persons responsible for
carrying out controls, the negative result of a molecular or antigen swab test, performed
in the 72 hours prior to entering Italy;
b) the obligation to take a molecular or antigen swab test, either upon arrival at the airport,
port or border location, if possible, or in any case within 48 hours after entering Italy,
under the supervision of the competent Local Health Authority; in the latter case, he/she
undertakes to self-isolate at his/her home or dwelling while awaiting the test:
Address:
Telephone number:
Competent Local Health Authority (where the test will be performed, unless carried out at
arrival):________________________________________________________________

F) none of the above.

If the letter F) applies, compile the following point 6:

6. the declarant did not transit or stay in any of the following countries in the 14 days prior to travelling to Italy:
Armenia, Bahrain, Bangladesh, Bosnia Herzegovina, Brazil, Chile, Colombia, Kuwait, North Macedonia,
Moldova, Oman, Panama, Peru, the Dominican Republic, Kosovo, Montenegro, Romania, and he/she fulfils
one of the following conditions (it is mandatory to circle one of the following options) :
G) he/she is entering Italy for reasons of work, health, or absolute necessity, and for no more than
120 hours;

H) he/she is transiting through Italy to return to his/her Country of residence or, in any case, the Country
in which he/she lives (with the permission to stay in Italy for no more than 36 hours);
I) he/she is a citizen or resident of one of the following countries and is entering Italy for proven work
reasons (circle the country of citizenship or residence): Italy, the Republic of San Marino, Vatican City State,
Austria, Belgium, Bulgaria, Cyprus, Croatia, Czech Republic, Denmark, Estonia, Finland, France,
Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland,
Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Iceland, Liechtenstein, Norway, Switzerland,
Andorra, Principality of Monaco, Australia, Canada, Georgia, Japan, New Zealand, Rwanda, the
Republic of Korea, Thailand, Tunisia, Uruguay, the United Kingdom;

L) he/she is a health worker entering Italy to practise their profession, also on a temporary basis, as
referred to in Article 13 of Decree-Law No. 18 of 17 March 2020;
M) he/she is a cross-border worker entering Italy for proven work reasons and then returning to their
place of residence, home, or dwelling;
 N) he/she is the employee of a company (or a sub-office of a company) based in Italy and who is
returning to Italy for proven work reasons after a period spent abroad not exceeding 120 hours;
O) he/she is an official or servant of any description of the European Union or any international
organisation, or a diplomatic agent, or a member of the administrative and technical personnel of a
diplomatic mission, a consular official or employees, a military or other law enforcement serviceman
travelling in the performance of their duties;

P) he/she is a student of a study programme in a Country other than their Country of residence, home,
or dwelling, to which he/she returns on a daily or weekly basis;

Q) he/she is entering Italy by express authorisation (to be shown if requested) issued by the Ministry
of Health (with the obligation to present to the carrier proof that, in the 72 hours prior to entering
Italy, he/she took a molecular or antigen swab test and tested negative);

R) none of the above.

If the letter R) applies, compile the following items:

7. the declarant fulfills any of the following conditions (it is mandatory to circle one of the following options):
S) he/she is a citizen of one of the following countries: Italy, Republic of San Marino, Vatican City
State, Austria, Belgium, Bulgaria, Cyprus, Croatia, Czech Republic, Denmark, Estonia, Finland,
France, Germany, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Malta, the Netherlands,
Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Iceland, Liechtenstein, Norway,
Switzerland, the United Kingdom, Andorra, Principality of Monaco, and did not stay or transit in one
or more of the following countries over the last 14-day period: Armenia, Bahrain, Bangladesh, Bosnia
Herzegovina, Brazil, Chile, Kuwait, North Macedonia, Moldova, Oman, Panama, Peru, the Dominican
Republic, Kosovo, Montenegro, Colombia;
T) he/she is a citizen of one of the Countries indicated under letter S and resides in Italy (before 9
July for those who, over the last 14-day period, stayed or transited from Armenia, Bahrain,
Bangladesh, Bosnia Herzegovina, Brazil, Chile, Kuwait, North Macedonia, Moldova, Oman, Panama,
Peru, the Dominican Republic; before 16 July for persons who stayed or transited from Kosovo and
Montenegro; before 13 August for persons who stayed or transited from Colombia);
U) he/she is the spouse/civil partner/cohabiting partner/lineal relative under the age of 21/lineal relative
and dependent/household member residing in Italy and dependent on a citizen of one of the States listed
under letter S).;
V) he/she is resident in Italy and, over the last 14-day period, did not transit or stay in one of the
following Countries: Armenia, Bahrain, Bangladesh, Bosnia Herzegovina, Brazil, Chile, Colombia,
Kosovo, Kuwait, North Macedonia, Moldova, Montenegro, Oman, Panama, Peru, the Dominican
Republic, Romania;
W) he/she is entering Italy (without having transited or stayed in one of the following countries over
the last 14 days: Armenia, Bahrain, Bangladesh, Bosnia-Herzegovina, Brazil, Chile, Colombia,
Kosovo, Kuwait, North Macedonia, Moldova, Montenegro, Oman, Panama, Peru, the Dominican
Republic, Romania) to travel to the domicile/dwelling/residence of a citizen of one of the following
 countries (Italy, the Republic of San Marino, Vatican City State, Austria, Belgium, Bulgaria, Cyprus,
Croatia, Denmark, Estonia, Finland, France, Germany, Greece, Ireland, Latvia, Lithuania,
Luxembourg, Malta, the Netherlands, Poland, Portugal, the Czech Republic, Romania, Slovakia,
Slovenia, Spain, Sweden, Hungary, Iceland, Liechtenstein, Norway, Switzerland, the United Kingdom,
Andorra, Principality of Monaco) or of a person residing in Italy, even if not a cohabiting partner, with
whom he/she has a proven and stable emotional relationship;
X) he/she is entering Italy from one of the following countries: Australia, Canada, Georgia, Japan, New
Zealand, Rwanda, the Republic of Korea, Thailand, Tunisia, Uruguay (without having stayed or
transited in the last 14 days, in countries other than Italy, the Republic of San Marino, Vatican City
State, Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France,
Germany, Hungary, Ireland, Latvia, Lithuania, Luxembourg, the Netherlands, Poland, Portugal,
Slovakia, Slovenia, Sweden, Iceland, Liechtenstein, Norway, Switzerland, the United Kingdom,
Andorra, Monaco);

Y) the declarant is entering Italy for essential work, study, urgent or health reasons or to return to his/her
home, dwelling or residence, not having transited or stayed, over the last 14 days, in any of the
following Countries: Armenia, Bahrain, Bangladesh, Bosnia Herzegovina, Brazil, Chile, Colombia,
Kosovo, Kuwait, North Macedonia, Moldova, Montenegro, Oman, Panama, Peru, the Dominican
Republic, Romania (please specify the essential reasons for travelling, in a clear and verifiable
manner):________________________________________________________________

8. the declarant will self-isolate, under the supervision of the competent health authorities, for 14 days, at the
following address:

Square (piazza) /street (via) no. flat no.

Municipality ____________________________________(Province_______) POSTECODE _ At
the home of:

9. upon arrival in Italy, the declarant will immediately and directly travel to the address specified above, in the
shortest possible time, with the following private or own means of transport:

10. the declarant will receive any communication, throughout the period of supervised self-isolation, at the
following telephone numbers: landline:____________ mobile:______________

Place: Date: Time:

Declarant’s signature Carrier’s signature