Ministry of Health Grenada

Travel Health Declaration Form

Date of arrival Passport number

12/06/2021 508193619

Name
John Gerard Gantz

Date of birth Age

01/29/1952 69

Email Telephone
johngerar.457320.a@govreply.ivisa.com (239) 273-0568

Address in Grenada
ST Gerorge Port louis
ST Gerorge Port louis
St GERORGE, St GERORGE

In the last 0 - 14 days have you had symptoms suggestive of COVID-19?

No

In the last 0 - 14 days have you had contact with (within 6 feet for more than 10 minutes) or cared for someone
with symptoms suggestive of COVID-19, or a suspected or confirmed case of COVID-19?
No

I have a negative Polymerase Chain Reaction (PCR) test or Nucleic Acid Amplification test (NAAT) taken within
72 hours of arrival in Grenada (date of sample collection must be within 72 hours (3 days) of arrival in Grenada)?
Yes

Are you fully vaccinated with a WHO approved COVID-19 vaccine?

Yes

Declaration

✔ I declare that the information I have given is true, correct, and complete. I acknowledge that giving a false answer to any
of the questions is an offence under the laws of the State of Grenada and that, on summary conviction, a fine of $10,000 or
imprisonment for 6 months or both may be imposed.”

Signature

Enter your full name Today's Date

John Gerard Gantz 11/30/2021

AdminEmail
covidhealthdesk@gmail.com