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
Place of Arrival: Shenzhen
From( Country/Region) :UK
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: London,
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 
Shortness ofbreath
Difficulty breathing 
Other disease
4. Have you had close contact with any probable or suspected Bird Flu case in the past 14 days?
Yes 
No
5. Please mark " √" before the items of the following articles if you bring any of them.
Animal 
Animalproducts 
Plant
Plant products 
Biological products
Waste and used clothing 
Soil
I hereby declare that all the information given above istrue and correct.
Date:November 16,2008
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℃ .
1. Who need to fill in this form?
A. Foreigners who want to take the Chinese nationality.
B. Foreigners who apply for entry to China.
C. Anyone planning to go to other countries from China.
D. Anyone planning to take animals to China.
2. The underlined word " sued" in the Note can be replaced by .
A. charged
B. sentenced
C. prevented
D. analyzed
3. Which of the following statements is NOT true according to the form?
A. It was by plane that Shirley Booth came to China.
B. Shirley Booth has been to at least four cities in the past month.
C. Shirley Booth brought some biological products with her.
D. Shirley Booth was not in good health after being examined.
