A/C page 2

ROMANIA 03 AUG 2021

AFFIDAVIT

Measure imposed by the Department of Public Health (DSP): DSP Signature:

c hospitalization o quarantine c isolation at the declared address
Name Surname
C.N.P. Date of birth (for foreign dtizens): day month year

~ Countryof departure

I declare on my own responsibility that:

I am aware that, in order to prevent the spread, within Romania, of the COVID-1 9 virus, I have an obligation to
comply with isolation! quarantine! hospitalization procedure, as appropriate:
For the application of the isolation! quarantine measure, after leaving the border crossing point, I will travel to
the following address on the shortest route: city street
.......... no bI ap
district!county
- I agree that personal data and information provided will be processed by the competent authorities;
I am aware of the provisions of article 326 of the Penal Code on false declarations and of article 352 of the
Penal Code on fighting against diseases.

While in Romania, I can be contacted at:

Phone’
Signature Date

AFFIDAVIT

Measure imposed by the Department of Public Health (DSP): DSP Signature:

u hospitalization n quarantine o isolation at the declared address
Name Surname
G.N.P. Date of birth (for foreign citizens): day month year

~ Gountryof departure

I declare on my own responsibility that:

I am aware that in order to prevent the spread within Romania of the COVID-19 virus, I have an obligation to
comply with isolation! quarantine? hospitalization procedure, as appropriate;
For the application of the isolation! quarantine measure, after leaving the border crossing point, I will travel to
the following address on the shortest route: city street no bI ap
sector!county
I agree that personal data and information provided will be processed by the competent authorities;
lam aware of the provisions of the article 326 of the Penal Code on false declarations and of the article 352 of
the Penal Code on fighting against diseases.

While in Romania, I can be contacted at:

Phone’
Signature Date

ROMATSA AIC A07/21

pag.2 AID
03 AUG 2Q21 ROMANIA

DECLARA]1E
Masura dispusã de DSP.: Semnátura DSP:
ci trimitere spre spital a carantinare institulionalizata a izolare Ia adresa declaratä
Nume Prenume
C.N.P. Data nasterli (pentru cetäeni straini): ziua luna anul

~ Tara de plecare

Declar pe propria räspundere cã:

am luat cunostintã de faptul ca pentru a preveni raspândirea pe teritoriul României a virusului COVID-19, ani
obIiga~ia de a ma supune procedurilor de izolare! cararitinare! internare, dupä caz;
pentru punerea In aplicare a mãsurii izolârh/carantiriárfl, dupá parasirea perimetrului punctului de trecere a
frontierei, ma voi deplasa pa tea mai scurtä rutá Ia urmãtoarea adresä: localitatea str nr.
bi ap sectoruL~ude1ul
sunt de acord ca datele cu caracter personal cj informa;HIe furnizate sá fle prelucrate de cätre autoritatile
competente;
am luat cunoØinla de prevederile art. 326 din Codul penal cu privire Ia falsul in declarath ci tale ale art. 352
din Codul penal cu privire Ia zädãrnicirea bolilor.

Pa perioada ~ederii in Romania p01 Il contactat Ia:

telefon
Semnatura Data

DECLARATIE
Màsura dispusä de D.S.P.: Sernnàturã DSP:
a trimitere spre spital a carantinare institulionalizata ci izolare Ia adresa declarata
Nume Prenume
C.N.P. Data nacterli (pentru cetäteni straini): ziua luna anul

j Tarn de plecare
Declar pa propria rãspundere ca:
am luat cuno~tina de faptul ca, pentru a preveni râspãndirea pe teritoriul RDmâniei a virusului COVID-19, am
obligatia de a ma supune procedurilor de izolare! carantinare! internare, dupà caz;
pentru punerea in aplicare a masuri izolarii/carantinarh, dupa parasirea perimetrulul punctulul de trecere a
frontierei, ma vol deplasa pe cea mai scurtä rota Ia urmãtoarea adresa: localitatea sIr nr.
bI ap sectorul/judelul
sunt de acord ca datele CU caracter personal ci informatNle furnizate sa lie prelucrate de cätre autoritalile
competente;
am luat cunoctinla de prevederile art. 326 din Codul penal cu privire Ia falsul in declaratü ci cele ale art. 352
din Codul penal cu privire Ia zãdãrnicirea bolilor.

Pe perioada çederü in Romania pot fi contactat Ta:

telefon
Semnätura Data

AID AQ7/21 ROMATSA