Passenger Locator Form

You are required to carry your vaccination certificate to be allowed by the border authorities to enter the country.

1. Personal
. . . . . . . Information -··············-······-·······-·······-······-·······-······-·

Last Name / Middle / First Name Sex / Age

GORZKOWSKI / - / ANDRZEJ Male / 62

Mobile Phone Number Business Phone Number Home Phone Number

Unique Code
+48514850757 - -
7182605668
Other Phone Number Email National ID
Date Submitted
- anna.gorzkowska@sp306.ed AUR224380
u.pl 2021-07-05

1. .Transportation
.... Information: Aircraft Flight Information
Airline name Flight number

ENTER AIR ENT1119

Date of arrival Point of Entry in the Country

2021-07-06 Skiathos

Connection Flight Information

Airline name Flight number Date of arrival

- - -

I Permanent Address
--------
Country State / Province City

Poland Mazowieckie WARSZAWA

Street (Name, Number, ZIP) Apartment Number / Previously Visited Country

Cabin Number
A.KRZYWON 2 01391 179

1 Temporary
..... Address --------------------------------------------------------------------------------------
Country State / Province City

Greece - SKOPELOS

Street (Name, Number, ZIP) Hotel Name (If Any) / Apartment Number / Cabin
Cruise Ship Name Number
Epar.Od. Skopelou-Loutrakiou, Neo ELIOS HOLIDAYS -
Klima 37003
 Passenger Locator Form

1. .Secondary
. . . . . . . . . . . . . . . . .Temporary
. . . . . . . . . . . . . . . . .Address
..........................................................
Country State / Province City

Street (Name, Number, ZIP) Hotel Name (If Any) / Cruise Apartment Number /
Ship Name Cabin Number

1. .Emergency
. . . . . . . . . . . . . . . . . .Contact
. . . . . . . . . . . . Information
..............................................................
Last (Family) Name First (Given) Name Country / City

GORZKOWSKA AGNIESZKA Poland / WARSZAWA

Mobile Phone Number Other Phone Number Email

+48507266629 - agnieszka.gorzkowska98
@gmail.com

1. . Travel
. . . . . . . . . . Companions
. . . . . . . . . . . . . . . . . . . . –. . .Family
...........................................................
Number Last (Family) Name / First Name Age Seat Number

1. . .Travel
. . . . . . . . . .Companions
. . . . . . . . . . . . . . . . . . . .–. . Non-Family
. . . . . . . . . . . . . . . . . ./. .Non-Same
. . . . . . . . . . . . . . . .Household
.......................
Number Last (Family) Name / First Name Group (Tour, Team, Business, Other)

1. . .Digital
. . . . . . . . . . Certificate
.................................................................................
First Name Last Name Passport / ID Number Expiration

ANDRZEJ GORZKOWSKI -/ - -

Type Manufacturer Country Certificate ID

Other Digital / Non Astra Poland -
Digital Zeneca/Oxford