DECLARATION

Measure disposed by the Department of Public Health (D.S.P): D.S.P. signature:

hospital admission institutionalized quarantine self-isolation at declared address

Name: Dangremont Surname: François-Xavier Régis Richard

C.N.P.: 110272300923 Date of birth: 1990 (year) 09 (month) 18 (day)
Country of departure: Franța

I hereby declare:
* I am aware that, in order to prevent the spread of the SARS CoV-2 virus in Romania, I have the obligation to abide by the
procedures of isolation/quarantine/hospital admission, as disposed.
* In order to self-isolate, after leaving the premises of the border crossing point, I will follow the shortest route to the following
address: Bulevardul 21 Decembrie 1989, 54-56, , , , CLUJ-NAPOCA, CLUJ,
* I agree to the use of my personal data and information found in this declaration by the competent authorities;
* I acknowledge the provisions of the art. 326 in the Penal Code regarding false statements and art. 352 regarding thwarting disease
control;
During my stay in Romania I can be reached at:
Phone number: +40751816930

Signature Date
26.10.2020