Page:United States Statutes at Large Volume 59 Part 2.djvu/349

 59STAT.] MULTILATERAL-SANITARY AERIAL NAVIGATION-JAN. 5, 1945 1015 International Sanitary Convention for Aerial Navigation, 1944 PERSONAL DECLARATION OF ORIGIN AND HEALTH (International Form) (For passengers on aircraft) Port of Arrival: 1. Name in full (BLOCK LETTERS, Surname first) 2. Nationality: 3. Passport number: 4. Permanent (home) address: 5. Precise address to which immediately proceeding: 6. State where you spent the fourteen nights prior to arrival in this country: Last night 8 nights ago 2 nights ago 9 nights ago 3 nights ago 10 nights ago 4 nights ago 11 nights ago 5 nights ago 12 nights ago 6 nights ago 13 nights ago 7 nights ago 14 nights ago 7. I am in possession of a certificate of inoculation or vaccination against: Cholera Yellow fever Typhus Smallpox 8. I declare that I have had no illness within the past fourteen days except as follows: I declare that the information given above is correct to the best of my knowl- edge and belief. Signature: Date:

�