DECLARATION

Measure disposed by the Department of Public Health (D.S.P): D.S.P. signature:

hospital admission institutionalized quarantine self-isolation at declared address

Name: Stan Surname: Gioni

C.N.P.: 1970128460031 Date of birth: 1997 (year) 01 (month) 28 (day)
Country of departure: Irlanda

I hereby declare:
* I am aware that, in order to prevent the spread of the SARS CoV-2 virus in Romania, I have the obligation to abide by the
procedures of isolation/quarantine/hospital admission, as disposed.
* In order to self-isolate, after leaving the premises of the border crossing point, I will follow the shortest route to the following
address: Orizont , 17, , , , 1 DECEMBRIE, ILFOV,
* I agree to the use of my personal data and information found in this declaration by the competent authorities;
* I acknowledge the provisions of the art. 326 in the Penal Code regarding false statements and art. 352 regarding thwarting disease
control;
During my stay in Romania I can be reached at:
Phone number: +40725521502

Signature Date
29.03.2021