Vermont Certificate of Compliance

Please familiarize yourself with the Vermont State Guidelines for Cross-State Travel before your visit.

Vermont Certificate of Compliance

Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Confirmation Number*
Date of Arrival*
1. I certify that:
a. I am traveling for essential purposes as defined by the State of Vermont; OR
b. It has been at least 14 days since my traveling party received the final COVID-19 vaccine dose, and therefore my party is exempt from the testing requirements; OR
c. I have traveled to Vermont from another state, and received a negative COVID-19 test within three days prior to my arrival in the state; OR
d. I have not left the state of Vermont for any reason except essential travel in the past 14 days; OR
e. I have left the state of Vermont, and upon return to the state received a negative COVID-19 test result within three days of my return; OR
f. I have had COVID-19 within the last 3 months, have recovered, and currently have no symptoms.
2. I also certify that, to my knowledge, I have not had close contact within the past 14 days with a person confirmed to have COVID-19.

3. I also certify that I am traveling only with members of my household, am staying in a lodging property with only members of my household, and I will only gather with vaccinated individuals or one additional unvaccinated household at a time outside of my household while in Vermont.

4. I also certify that I do not currently have, and have not had in the past 24 hours, any of the following symptoms:
• Cough;
• Difficulty breathing;
• Fever (feeling feverish or have a measured temperature at or above 100.4°F/38°C);
• Chills;
• Repeated shaking with chills;
• Muscle or body aches;
• Headache;
• Sore throat;
• New loss of taste or smell;
• Congestion or runny nose;
• Nausea or vomiting, diarrhea

5. I also certify that all persons in my care who are under the age of 18 or who are dependent on my care meet the criteria described in items 1–3 above.
Please provide a list of the names of all such persons in your care:
6. By way of this form, I have been informed that out-of-state guests are encouraged to register with the Vermont Department of Health’s Sara Alert system* and to provide updates to that system daily.
*
- 7. I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury.
Name*
First Last
Date Signed*
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