遠雄悅來大飯店-健康聲明書
配合政府防疫政策，請您誠實回答下述項目:

For epidemic prevention, please fill in and submit this form accurately.
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1. 請問您或他人(含同住者、同行者)近期 14 天內有出入境哪些國家/地區(含轉機)? 若您選擇 ”其他” 請說明您到訪過的國家/地區。Have you (including co-residents, visitors) visited or transited any countries in the past 14 days? If you select "Other", please reply to the country you visited. *
2. 請問您或他人(含同住者、同行者)是否有發燒(高於或等於 37.5°C)、呼吸道症狀、咳嗽喉嚨痛、全身無力等類似嚴重特殊性傳染性肺炎症狀？ Are you (including co-residents, visitors) having symptoms such as fever (equal or higher than 37.5 degree Celsius), shortness of breath, difficulty in breathing, cough, sore throat, extremely fatigue, muscle ache? *
3. 請問您或他人(含同住者、同行者) 是否接獲「自主健康管理通知書」、「居家隔離通知書」、「旅客入境健康聲明暨居家檢疫通知書」? Have you (including co-residents, visitors) received the Notice on Self-Management of Health or Home-Isolation /Home Quarantine Notice? *
※ 如有規避妨礙、填寫不實者，將依傳染病防治法第 58 條及同法第 69 條提報相關主管機關處理。 According to articles 58 and 69 of the Communicable Disease Control Acts, all are required to accurately report his/her travel history without any concealment. Any person who refuses, evades or obstructs abovementioned measures would be reported to governmental authorities.
※ 若因隱匿居家檢疫事實或違反相關事項導致飯店損失，本飯店將保留法律追訴權。 Once any violation of quarantine or related regulation results in losses of the hotel, Farglory Hotel Hualien will reserve the right to pursue legal action.
4. 本人已閱畢並且同意上述之說明。I certify that I have read the information above and will cooperate with Farglory Hotel Hualien. *
5. 若您非本國籍人，請選擇 "其他" 並說明國籍。If you are not of Taiwanese nationality, please select "Other" and reply your nationality. *
6. 姓名 Name *
7. 身分證字號或護照號碼 ID Number/Passport Number *
8. 電話 Telephone Number *
9. 入住日期 Arrival Date *
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