Negative Test Declaration Form
You must submit this declaration form before your boarding or travel.
Personal Data
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Nationality
Test Information
I have been tested for the presence of COVID-19 on the following date and time.
Local Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
UTC Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
Name of the Certifying Medical Doctor
First Name
Last Name
Name of the Institution
Testing Result
Negative/Not Detected
Positive/Detected
Inconclusive
File Upload (if applicable)
Browse Files
Drag and drop files here
Choose a file
Please upload PCR, antibody or antigen test result.
Cancel
of
Signature
I declare that the information provided in this form is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: