Reference ID: SP21MZD3

Date of issue: 27-Dec-2021 01:14 PM

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Date of travel: 27-12-2021

Pass expires on: 10/01/2022

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Please note: This Travel Declaration is only valid for 14 days from the date of issue and can be used for
multiple trips or until your circumstances change, whichever is shorter. The pass is void and a new pass
required if after the date of issue of this pass you travel to a declared COVID-19 hotspot, you visit a
interstate exposure venue during the relevant exposure period or the Queensland Travel Declaration
Direction or Border Restrictions Direction is updated within the 14-day period. Please check the current
information at https://www.qld.gov.au/health/conditions/health-alerts/coronavirus-covid-19/current-
status/contact-tracing before travelling.

Personal details

People travelling: Adrian Lim

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Dependents: None

Contact number: 0414939005

Email: docadrianlim@gmail.com

Residential/Home address: 98 HIGH ST NORTH SYDNEY NSW 2060

Page 1 of 3 Queensland Government

 Travel details

Pass status: Green

Origin/Coming from: Australia

Destination Location: Brisbane

Destination Mode of Travel: Road

Green Queensland travel declaration means:

You have not been to a COVID-19 hotspot (in Australia or New Zealand) or an interstate exposure venue
and you must:

get tested if you develop any COVID-19 symptoms after arriving in Queensland.

monitor the list of interstate exposure venues every day from the time you completed this Declaration

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and for 14 days after entering Queensland.

Declaration

You have answered no to being in a declared COVID-19 hotspot and no to being in an interstate

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exposure venue. You will be issued with a Green Travel Declaration.

I/We have declared that I/we, and any person under the age of 18 or a dependent named within this
Travel Declaration travelling with me, will comply with all the conditions outlined below.

I/We have undertaken to monitor for COVID-19 symptoms and get tested immediately if they appear
and will remain at our place of residence/accommodation until a negative result is received or until
otherwise advised by Queensland Health. Symptoms which are consistent with COVID-19: fever or
history of fever, symptoms of acute respiratory infection (cough, shortness of breath, sore throat), loss
of smell, loss of taste, runny nose, diarrhea, nausea, vomiting or fatigue.

I/We have confirmed I/we have not been in any Interstate exposure venues or an area listed as a

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COVID Hotspot (as defined on the Queensland Health website) in the last 14 days prior to entering
Queensland.

I/We understand if my/our circumstances change after receiving my/our Travel Declaration, then our
travel declaration is void and I/we will need to reapply. Examples of a change in circumstances
include: Interstate Exposure venues or a COVID-19 hotspot has been declared.

I/We have agreed to check the interstate exposure venues website for venues every 24 hours from the
time I/we completed this Declaration and for 14 days after my/our arrival to Queensland. If a venue is
listed that I/we have visited at the stated date and time, I/we will follow the instructions on the
Queensland Health website.

If I/we have completed hotel quarantine within the 14 days prior to arrival in Queensland, proof of exit
will be shown to an Emergency Officer General (Queensland Police Service, Public Health or other
appointed Government Officers) if requested.

I/We have agreed to comply with all current Queensland Health Public Health Directions, alerts,
messaging or instructions provided by an Emergency Officer General (Queensland Police Service,
Public Health or other appointed Government Officers).

I/We have agreed to carry this declaration (printed or electronically) for 14 days after entry into

Page 2 of 3 Queensland Government

 I/We have agreed to carry this declaration (printed or electronically) for 14 days after entry into
Queensland and will show this declaration to an Emergency Officer General (Queensland Police
Service, Public Health or other appointed Government Officers) if requested.

I/We acknowledge that knowingly providing false, misleading or incorrect information is an offence
under the Public Health Act 2005 punishable by an on-the-spot fine of $1,378 or a court-imposed
penalty of up to $13,785 or 6-months imprisonment.

✔ I/We declare all information I/we have given in this application is true and correct.

Note
Interstate Exposure Venue – Venue/s that have been identified by Contract Tracers as places visited by
an infected person. If you have been to an interstate exposure venue you must quarantine when entering
Queensland. If you enter Queensland before the identified date published on the Queensland Health
website, you will be required to quarantine at home or other suitable accommodation until 14 days have
passed since you visited the relevant interstate exposure venue. If you enter Queensland after the
identified date published on the Queensland Health website, you will be required to quarantine at a
government-nominated hotel at your own expense for 14 days. If an interstate exposure venue that you
have visited is published after you arrive into Queensland you must immediately travel by private

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transport directly to your home or another suitable accommodation residence to quarantine, complete
the contact tracing form available on the Queensland Health website and continue to quarantine until
you get further instructions from Queensland Health. The contact tracing form is available at:
https://www.qld.gov.au/health/conditions/health-alerts/coronavirus-covid-19/current-status/contact-
tracing.

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COVID Hotspot – Only returning Qld residents or people entering for a limited range of essential
purposes who have been in a COVID-19 hotspot in the previous 14 days or since the start date identified
for the hotspot, whichever is shorter, will be allowed to enter Qld via air only (Border Pass required). If
you arrive into Qld from a hotspot you will be required to hotel quarantine for 14 days. Anyone who is not
a Qld resident or one of the limited range of people permitted to enter Queensland, and who has been in
a hotspot in the previous 14 days or since the start date identified for the hotspot, whichever is shorter,
and wishes to enter Qld will require an exemption.

Place of Concern – A location identified within a State or Territory where if a person has been in that
location they are required to stay at home in Queensland in line with the relevant State or Territory’s
lockdown rules or as otherwise required under the Places of Concern Direction (No.3) or its successor.

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Area of Concern – Interstate areas of concern are places in Australia that present an increased COVID-19
risk, that is not as high as hotspots. They do not restrict people from entering Queensland, however you
should follow local movement or travel rules before coming to Queensland.

Anyone who has been in a COVID-19 interstate area of concern in the last 14 days or since the identified
start date (whichever is shorter) cannot enter a Queensland residential aged care facility, hospital, or
disability accommodation service. Certain people may enter a residential aged care facility, hospital, or
disability accommodation service after being in an interstate area of concern if they have received a
negative result. If you have been in an interstate area of concern and experience any symptoms, no
matter how mild, you must get tested immediately and isolate until you receive your results.

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