D
ENTRY-EXIT INSPECTION AND QUARANTINE
THE PEOPLE’S REPUBLIC OF CHINA
HEALTH AND QUARANTINE DECLARATION FORM ON ENTRY
Name: Shirley_Booth Sex: Male √ Female
Birth Date: 1959_yy_02_mm Nationality（Region）: American
Time of Arrival: 17:20_hh_ Place of arrival: Shenzhen
From（Country/Region）: USA Passport No．: CA5728019
Vehicle/ Ship/Flight No．: Flight_UA_3625 Seat No．: 16E
Destination: Changsha,_Hunan
1．Please list the countries and cities（towns） that you have visited in the past 4 weeks:
New_York,_Paris,_Tokyo_and_Hong_Kong
2．The contact address and telephone number in the next 14 days:
Changsha_Friendship_Hotel
3．Please mark “√” before the items of following symptoms or illness if you have any now．
Fever Cough Other disease
Shortness of breath Difficulty breathing
4．Have you had close contact with any probable or suspected H1N1 case in the past 14 days? Yes √ No
5．Please mark “√”before the items of following articles if you bring any of them．
Animal Animal products Plant Plant products
√ Biological products Waste and used clothing Soil
I hereby declare that all the information given above is true and correct．
Date: April_16,_2009 Signature: Shirley_Booth
Note:
1． For the health of all, please give true and correct information;
2． You will be sued according to related laws if you give the false information;
3． No entry shall be allowed without the declaration;
4． Body temperature: 37°C
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68．When does one need to fill in this form?
A．Permissions for a foreigner to take the Chinese nationality．
B．Entry to China from other countries or regions．
C．Exit to other countries or regions from China．
D．Anyone planning to take animals to China from other countries or regions．
69．The underlined word “sued” can be taken the place of by _____．
A．charged B．sentenced C．prevented D．analyzed
70．Which of the following statements is false according to the form?
A．It was not by ship that Shirley Booth came to China．
B．Shirley Booth went to at least three continents during March16-April 16, 2009．
C．Shirley Booth brought some biological products with her．
D．From the form we know Shirley Booth was not in good health．
