Travel Attestation Form

Travel Attestation Form
All individuals entering our State who do not fall within certain, limited exemptions must complete this form upon or prior to entry. Failure to complete the form and comply with the precautionary measures may result in a capital punishment.
Following the entrance all travellers are required to self quarantine for 10 days unless:
1. are coming from a low-risk state
2. can procedure, on request, proof of negative test result taken not longer than 72 hours before arrival
3. meet the exemption criteria
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Country/State Before Arrival
Arrival Date
MonthDayYear
Date
Departure Date (optional)
MonthDayYear
Date
Where you are staying
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Dependants
COVID-19 Health Status
I have received a negative test result for COVID-19 on a specimen taken no longer than 72 hours prior to my arrivalI plan to get a test at my cost and will remain in quarantine until I receive a negative resultI have taken a COVID-19 test and am awaiting my result and will remain in quarantine until I receive a negative resultI will quarantine for 10 days upon arrival or for the duration of my stay if fewer than 10 daysOther
By clicking, I certify I do not currently have COVID-19 symptoms; have not had close contact with anyone in the last 10 days who is confirmed or suspected to have COVID-19; will wear a mask while in public; and will maintain 6 feet of physical distance from others.By submitting this form, I hereby attest, under penalty of law, that all the information I have provided is true and accurate to the best of my knowledge
Signature
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