Negative Test Declaration

COVID-19
You must keep this Negative Test Declaration with you for verification purposes during travel and on arrival.

You must show this declaration and the negative test result itself when boarding the aircraft or ship, or when requested to do so by
airport or ship staff or the designated (medical) authority, such as the Royal Netherlands Marechaussee. Otherwise, you may be denied
entry to the Netherlands or the aircraft or ship.
The information you provide may be used by the public health authorities, in accordance with Dutch legislation and in the context of
the public health response to COVID-19. Travellers aged 13 and over from outside the Schengen area are required to complete this
declaration. There are some exceptions; see www.government.nl.

1 Personal data

1.1 Name |

1.2 Nationality |

2 Test information
> Has been tested by PCR-test for the presence of COVID-19 (SARS-CoV-2) on:

Date (ddmmyyyy) Time (hh:mm)

2.1 Local date and time

Date (ddmmyyyy) Time (hh:mm)

2.2 UTC date and time

Name

2.3 Name of the certifying |

medical doctor or
institution that
performed the test

2.4 Testing result n Negative / Not detected n Positive / detected n Inconclusive

3 Signature

3.1 Date

3.2 Signature I declare under penalty of forgery that the foregoing is true and correct.

Add your signature here

VWS_DCo_2020.11