Avaa tulostettava versio tästä:

Certificate of exemption

This is to certify that

Mr / Mrs / Miss. . . . . . . . . . . . . . . . . . . .

date of birth . . . . . . . . . . . . . . . . . . . . .

has not been vaccinated against yellow fever because of / due to

. . . . . . . . . . . . . . . . . . . . . . . . .

and the vaccination therefore is contraindicated.

Date . . . . . . . . . . . . . . . . . . . . . . . .

Physician. . . . . . . . . . . . . . . . . . . . . .

Official vaccination stamp