SELF DECLARATION FOR ENTRY INTO ITALY FROM ABROAD

(to be delivered to the carrier when using public transport)

The undersigned _______________________________________, born on ___/___/______ in

(Province ____), a ______________________
citizen, resident in (Province___ ), street
address________________________

aware of the criminal penalties applicable in the event of false declarations and of the creation or use
of false deeds, as well as of the penalties provided for by article 2 of Law Decree No. 33 of 16 May
2020

DECLARES UNDER HER/HIS OWN RESPONSIBILITY

1. to be aware of the COVID-19 containment measures in force in Italy and, in detail, of the
provisions included in the decrees of the Prime Minister dated 7 August 2020 and 7 September
2020;

2. to have not been tested positive for the coronavirus or, if tested positive following an RT PCR
test carried out abroad, to have strictly complied with the health protocols laid down by the
authorities of the country where the test was carried out, to have observed 14 days of isolation
since the last date of occurrence of symptoms, and not to be subject to quarantine measures by
the local authorities;

3. to enter into Italy from the following foreign location

______________________________________, by means of the following means of transport (in
the case of private means of transport please indicate the type of vehicle and plate number; in
case of public transport please indicate flight/rail or road/sea route details):
________________________________________________________________________________

4. to have stayed/transited in or from the following countries and territories in the last 14 days:
________________________________________________________________________________

5. to be in one of the following conditions (it is mandatory to circle one of the options):
A) crew or travelling personnel;
 B) entry into Italy from San Marino or the Vatican City State;
C) entry into Italy for work reasons regulated by specific safety protocols, approved by the
competent health authority;
D) entry into Italy from one of the following countries (without stays or transits, in the last
14 days, in countries other than the following): Austria, Belgium, Cyprus, Denmark,
Estonia, Finland, France, Germany, Ireland, Latvia, Lithuania, Luxembourg, Netherlands,
Poland, Portugal, Czech Republic, Slovakia, Slovenia, Sweden, Hungary, Iceland,
Liechtenstein, Norway, Switzerland, United Kingdom, Andorra, Monaco;
E) entry into Italy after having stayed or transited, in the last 14 days, in or from one of the
following countries: Croatia, Greece, Malta, Spain. In this case the following preventive
measures apply alternatively:
a) an obligation to deliver a declaration to the carrier at the time of boarding, as
well as to anyone in charge of carrying out checks, whereby it is confirmed to
have undergone a molecular or antigen test, carried out by means of a swab and
with a negative result, within 72 hours prior to entering the national territory;
b) an obligation to undergo a molecular or antigen test, to be carried out by means
of a swab, upon arrival at the airport, port or border location, where available,
or within 48 hours of entry into the national territory at the local health office;
while waiting to undergo the test at the local health office, to stay in fiduciary
isolation at one’s house or dwelling:
Address: ___________________________________________________________________________

Telephone number: __________________________________________________________________

Local Health Authority of reference (where the test will be carried out if not carried out upon arrival):

_________________________________________________________________________________

F) none of the above cases.

Only if the letter F) has been circled, please fill in point 6 as well:

6. not to have transited or stayed, in the 14 days prior to entering Italy, in or from one of the
following countries: Armenia, Bahrain, Bangladesh, Bosnia Herzegovina, Brazil, Bulgaria, Chile,
Colombia, Kuwait, North Macedonia, Moldova, Oman, Panama, Peru, Dominican Republic, Kosovo,
Montenegro, Romania, Serbia; and to be in one of the following conditions (it is mandatory to circle
one of the options):
 G) need to enter into Italy for reasons of work, health or absolute urgency and for a
maximum duration of 120 hours;
H) transit through the national territory to return to one’s country of residence or stay
(maximum permitted stay in Italy: 36 hours);
I) entry into Italy, for proven work reasons, by citizens or residents of one of the following
countries (circle the country of citizenship or residence): San Marino, Vatican City State,
Austria, Belgium, Cyprus, Croatia, Denmark, Estonia, Finland, France, Germany, Greece,
Ireland, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Czech
Republic, Slovakia, Slovenia, Spain, Sweden, Hungary, Iceland, Liechtenstein, Norway,
Switzerland, United Kingdom, Andorra, Monaco, Bulgaria, Romania, Australia, Canada,
Georgia, Japan, New Zealand, Rwanda, Republic of Korea, Thailand, Tunisia, Uruguay;
L) health personnel entering into Italy for the exercise of health professional qualifications,
including the temporary exercise referred to in Article 13 of Law Decree no. 18 of 17
March 2020;
M) cross-border workers entering into Italy for proven work reasons or to return to their
place of residence or dwelling;
N) employees of companies having their registered office or branch in Italy, returning to
Italy for proven work needs and after a stay abroad of no longer than 120 hours;
O) officials and other servants of the European Union or international organisations,
diplomatic agents, administrative and technical staff of diplomatic missions, officials and
consular officers, military personnel and police officers in the performance of their
duties;
P) pupils and students attending a course of study in a country other than their country of
residence or dwelling, to which they return every day or at least once a week;
Q) entry following an express authorization (to be provided in case of checks) issued by the
Ministry of Health (with the obligation to provide the carrier with the declaration to
have undergone a molecular or antigen test by means of a swab with a negative result
within 72 hours before entry);
R) none of the above.

Only if the letter R) has been indicated, please also fill in the following items:

7. to be in one of the following conditions (it is mandatory to circle one of the options):
S) citizen of one of the following countries: Italy, San Marino, Vatican City State, Austria,
Belgium, Cyprus, Croatia, Denmark, Estonia, Finland, France, Germany, Greece, Ireland,
 Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Czech Republic,
Slovakia, Slovenia, Spain, Sweden, Hungary, Iceland, Liechtenstein, Norway, Switzerland,
United Kingdom, Andorra, Monaco, Bulgaria, Romania, that has not stayed or transited,
in the last 14 days, in or from one of the following countries: Armenia, Bahrain,
Bangladesh, Bosnia Herzegovina, Brazil, Chile, Kuwait, North Macedonia, Moldova,
Oman, Panama, Peru, Dominican Republic, Kosovo, Montenegro, Serbia , Colombia;
T) citizen of one of the countries listed under letter S, residing in Italy (before 9 July for
those who have stayed or transited, in the last 14 days, in or from Armenia, Bahrain,
Bangladesh, Bosnia Herzegovina, Brazil, Chile, Kuwait, North Macedonia, Moldova,
Oman, Panama, Peru, Dominican Republic; before 16 July through Kosovo, Montenegro,
Serbia; before 13 August through Colombia);
U) married/civil partner/cohabitant/direct descendant under 21 years of age/descendant
or direct dependant ascendant/family member residing in Italy and dependent on a
national of one of the countries listed under letter S);
V) person residing in Italy that has not transited or stayed, in the last 14 days, from or in
one of the following countries: Armenia, Bahrain, Bangladesh, Bosnia Herzegovina,
Brazil, Bulgaria, Chile, Colombia, Kosovo, Kuwait, North Macedonia, Moldova,
Montenegro, Oman, Panama, Peru, Dominican Republic, Romania, Serbia;
W) entry into Italy (without having transited or stayed, in the last 14 days, from or in one of
the following countries: Armenia, Bahrain, Bangladesh, Bosnia Herzegovina, Brazil,
Bulgaria, Chile, Colombia, Kosovo, Kuwait, North Macedonia, Moldova, Montenegro,
Oman, Panama, Peru, Dominican Republic, Romania, Serbia) to reach the
domicile/residence/dwelling of a citizen of one of the following countries (Italy, San
Marino, Vatican City State, Austria, Belgium, Cyprus, Croatia, Denmark, Estonia, Finland,
France, Germany, Greece, Ireland, Latvia, Lithuania, Luxembourg, Malta, Netherlands,
Poland, Portugal, Czech Republic, Slovakia, Slovenia, Spain, Sweden, Hungary, Iceland,
Liechtenstein, Norway, Switzerland, United Kingdom, Andorra, Monaco, Bulgaria,
Romania) or of a person residing in Italy, even if not cohabiting, with whom there is a
proven and stable relationship;
X) entry into Italy from one of the following countries: Australia, Canada, Georgia, Japan,
New Zealand, Rwanda, Republic of Korea, Thailand, Tunisia, Uruguay (without any stays
or transits, in the last 14 days, in or from countries other than the above and from Italy,
San Marino, Vatican City State, Austria, Belgium, Cyprus, Denmark, Estonia, Finland,
France, Germany, Ireland, Latvia, Lithuania, Luxembourg, Netherlands, Poland, Portugal,
 Czech Republic, Slovakia, Slovenia, Sweden, Hungary, Iceland, Liechtenstein, Norway,
Switzerland, United Kingdom, Andorra, Monaco, Bulgaria, Romania);
Y) entry into Italy for reasons of health, work, study or absolute urgency or in order to
return to one’s house, dwelling or residence, not having transited or stayed, in the last
14 days, from or in one of the following countries: Armenia, Bahrain, Bangladesh, Bosnia
Herzegovina, Brazil, Bulgaria, Chile, Colombia, Kosovo, Kuwait, North Macedonia,
Moldova, Montenegro, Oman, Panama, Peru, Dominican Republic, Romania, Serbia
(please indicate in a specific, actual and verifiable way the reasons for the move and
their urgency and necessity):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

8. that will carry out the 14-day period of health surveillance and fiduciary isolation at the
following address:
square/street _______________________________________ no. _________________
Municipality __________________ (Province_____) ZIP CODE______________ at:
_____________________________

9. that, once arrived in Italy, she/he will reach directly and in the shortest possible time the
address indicated in the previous point by the following private means, or own means:
__________________________________________________________________________________
__________________________________________________________________________________

10. that the telephone numbers at which communications are to be received during the entire
period of health surveillance and isolation are the following:
landline number: _____________________ mobile: __________________________

Place: _________________ Date: ________________ Time ________________

Signature of the passenger for the Carrier