j v or ION PROPHYLAXIS

IN IONAL PROPHYLAXIV
M LOUNAROJ)NA ro VJO)A O JU

Ihis is to ecdify that (nanic)

Nous certificates que (noni)
PotsTduge se daje (i:ne)

nationality national identity docurnent, if' applicable

et de nationalite.. docujnent d'identification national, lc cas échéarit
nacionalnost nacionalni identifikacijski dok urnenti po potrcbi

hose signature follows

dent la signature suit
éiji potpis slijedi
has on the date indicate(i been vaccinated or received prophylaxis against (na;nc
a été vacciné(e) ou a requ des agents prophylactiqucg å la date date indiquée contre
bio (la) cijepljen (a) ili primio profilaksu protiv: (irne bolesti ili stanja)

m the Intemational Health Regulations. / ccr)fon-nérnent au Réglernent sanitaire / u

Vaccine or prophylaxis Date Signature and professional Manufacturer

Datum status of supervising batch No. oivacc;ne or
Vaccin ou agent prophilactique clinitian prophylaxis
Signature et titre du Fabricant du vacc;n ou
Vakcina ili profilaksa clinicien responsable de ragent prophy}actique
Potpis i p0102aj et nuJ1iéro c.iu
odgovornog Iijeénika Proizvodaé i scrija
iii se