Declaration for international travel

Details of the traveller

Given Name(s):

Lazurca Ovidiu Iulian

Date of Birth (dd/mm/yyyy):

20/12/1982

Nationality:

romanian

Home address:

Marlow Road 15, Lomdon, UK, E6 3QG

Passport number, or travel document reference number (as appropriate):

054551289

Destination:

Vaslui, Romania

Date of travel:

22/12/2021

I hereby declare that my reason for being outside my home to travel internationally is for:

Work
Volunteering
Education
Medical, or compassionate reasons
Funeral
Ending a temporary visit (non-UK resident)
Allowing access to parents with children who do not live in the same country
Other reasonable excuse – please specify:
Declaration
I certify that the information I have provided is true. I understand that if I provide false or
misleading information, I may be issued with a fixed penalty notice and/or a direction to return
home; or be arrested.

Signature:

Lazurca Ovidiu Iulian

Date (dd/mm/yyyy):

16/04/2021