EU Digital Passenger Locator Form (dPLF) English !

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EU Digital Passenger Locator Form (dPLF) – Please fill this form in English

Declaration
Declaration according the art. 50 of DPCM 02/03/21 to enter Italy

Date of Birth

2002-05-13

Place of Birth

HUBEI,HUANGSHI

Country of birth

China/CN % &!

Province

Hubei/42 !

Citizenship
This field is required

I am aware I shall be liable to prosecution if any statement to a public officer is found to be false, pursuant
to art. 46 and 47 D.P.R. n 445/2000

' I also hereby declare, under my own responsibility, that even as a parent or guardian of the minor/s listed below

Minor(s)

ADD

I am aware of the containment measures of COVID-19 in force in Italy and, specifically adopted in
accordance with the Decree of the President of the Council of Ministers March 2nd, 2021

I have been / transit in the following countries and territories in the last 14 days:

China/CN % &!

I will enter in the following Italian Region

Trentino-Alto Adige/32 !

Travelling from a Country of the List?

Check in which List is your departure country

( List C (EU/EEA/Israel)

List D (Albania, Saudi Arabia, Armenia, Australia, Azerbaijan, Bosnia and Herzegovina, Brunei, Canada,
United Arab Emirates, Japan, Jordan, Lebanon, Kosovo, Moldova, Montenegro, New Zealand,
Qatar, United Kingdom of Great Britain and Northern Ireland(including Gibraltar, the Isle of Man, Channel
( Islands and British bases on the island of Cyprus and excluding territories not belonging to the European
continent), Republic of Korea, Republic of North Macedonia, Serbia, Singapore, United States of America,
Ukraine, Taiwan, Hong Kong and Macao Special Administrative Regions)

) List E

I am travelling for any of the following reasons:

( Proven work requirements

( Absolute Urgency

( Health Needs

) Study Needs

( Returning home, residence

Entering the national territory as citizen of a member states of the European Union, member states of
( the Schengen Agreement, the United Kingdom of Great Britain and Northern Ireland, Andorra, the
Principality of Monaco, the Republic of San Marino, of the Vatican City State

Entering into the national territory as a family member of the natural persons referred to in the previous
( point as deaned by articles 2 and 3 of Directive 2004/38 / EC of the European Parliament and of the
Council of April 29th, 2004

Entering the national territory as long-term resident of third country nationals pursuant to Council
( Directive 2003/109 / EC of November 25, 2003

Entering the national territory as family members of the natural persons referred to in the previous point
( as deaned by articles 2 and 3 of Directive 2004/38 / EC of the European Parliament and of the Council of
29 April 2004

Entry into the national territory to reach the home or residence of a person referred to in letters f) and h),
( even if not cohabitant, with whom there is a proven and stable emotional relationship

Travellers entering by means of Covid-Tested ?ights in accordance with the Order of the Minister of
( Health of 14 May 2021

In this regard, I declare that (Optional)

Quarantine information (for any details click here)

Are you in any of the exemptions provided by the art. 51 of the DPCM of 02/03/21? If yes please indicate
which one

( Yes

) No

Do you have an Exemption issued by the Italian Ministry of Health?

( Yes

) No

This field is required

' I will notify my arrival in Italy to the Local Health Authority

Full address of the place or residence in Italy where the period of health surveillance and quarantine will
be carried out fiduciary isolation
This field is required

The private means of transport that will be used to reach the place of quarantine 1) or, exclusively in the
case of entry into Italy by scheduled air transport, additional scheduled air transport which is expected to
be used to reach the place of final destination and the identification code of the identification code of
the travel document
This field is required

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Contact e-mail: eudplf@healthygateways.eu

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