Declaracin rada de Salud del Vijero para preven el coronavirus (COVID-18) Health Affidavit for travelers to prevent coronavirus cOVI0-18) Je ttrmscén person Documenta devaje pate Papo] OND ) OxroOther( Travel document Tipo/Type nomerosnumber fa Ts [41/7 [eg ie le aS E ‘noe ane eee Nacionslaaa/nationsIEy ” elWe Ail Fecha ce nscimiena/Detedbeth Tacha ca agate Paa/ Date En Pa Daymes/ate/DayMontvvear (3/2/1959 Dis/vee/Ato/Dayont ear Liplron Toisas pocedenda court org Grsiee Medio de transporte da warare a Per/aans of Warspor To erty into Feu ‘Abroo/AirTeansportation {_ | Terrestre/land transport { ) Martimo/Maritime Transportation (of Otro/Other { } Worire dela empresa de fi" de velo Worspore[Fighv/TerapoMalion number Pllmero de eienta/Sent sumer ransporesfenterrse "Telfenas de contac igs palescodadon mere] Conta pane number (eure Cader cyanaba +30 2 1990 009 Cares tala, dol wom Traian nr pasar 0 cudades en fos Que estvo os uTttnag i das / Indicate The courvies ov cles where you weve ver heat IS daye Lrmuak Pou II. siustedes residente en Perd/if you are resident in Perd Deel seal Curent address AIL. ict éestino finales Perf your Final destiny is Per Tndique los domicionyGudades durante su permanencia en Prd Indicate the addresses and cies during your ayn Pera Cada / iy. Hotel (Hote Direclsnjtaess, Cede / cy Hotel Hotel Drecisn/tesese, Chadd / cy Hotel Hotel Direcibn/address, IV. aniecedentes de salud/Health information Ted tendo contacto con aga papa erferna de Coronavirus (COVID-18)/Have you tac contact with any person wth Covonevins [COMD-1S) Sines 1) NoINO ‘talento, sted presanta aigune de itor Thvomas/careniy do you Fave any ol these smpions Febre/Fever' (-) Tot/Cough { ) Dolor deaarganta/Soretnvast () Problemas para respirarfificl breathing vo. wo Feera/oate Frmaienatg DiayMes/Afo/Oay)Month/vese 34/2020 Este documerto iene cricter de etlaracion juradayla informacion est proteyda por la Ley N" 25733 Ley de protectin de datos personales. “his €ocument ha the charastr ofan affidavit and tha information in iis protected bythe Law Ho, 29733 - Law on protection of personal dats Para mayor informacion sobre el coronaius (COVID-18) puede lamar al 113 -INFOSALUD More intarnation about earenavirus(COViD-19) cll to 113 -INFOSALUD