Isolation Exemption Certificate
(For submission to the Immigration Officer)
( f i l l e d b y t h e A p p l i ca n t )
Applicant information
Name Gender [ ] Male
[ ] Female
Nationality Date of birth
Passport No. Mobile phone number
(Contact information in Korea)
Status of stay
Address in Korea ※ Please provide a full address
Affiliation (Company name) Reference in Korea
(Contact information)
Last place of departure Date of departure
Flight No. Time and date of arrival
Period of visit Expected date of departure from Korea
( f i l l e d b y t h e E m b a s s y o r C o n s u l a t e )
Purpose of visit
※ △중요한 사업상(계약, 투자, 기술 지원 등) 목적, △학술적 목적(국제학술행사 등), △기타 공익적 또는 인도적 목적 등에 대한 상세 사유 적시
- 예시) 계약·투자 목적(기관명, 담당자, 계약·투자내용 등) / 학술적 목적(행사명, 주관기관 담당자, 행사일 등)
Submitted
documents ※ 초청장(초청 이메일 포함), 계약서(안), 가족관계증명서 등(여권 사본은 필히 징구)
Although the person above is subject to the Special Entry Procedure upon arrival in Korea and isolation for 14 days after the entry, the person applied for exemption from isolation for reasons as stated above. The officer in charge reviewed the request and hereby grants exemption to the applicant.
※ Isolation exemption certificate applies to foreign nationals with short-term visas (B1, B2, C1, C3, and C4) and long-term visas (D8 and D9) as well as Korean nationals.
※ You will stay in a temporary isolation facility for two days for testing. If tested negative, you will be exempt from isolation requirement.
※ In spite of this certificate, you will be isolated for treatment if tested positive.
※ You should follow the instructions of the health authority to install the Self-diagnosis App on your smartphone and report your health status everyday through the app. You will also receive a phone call on a daily basis from a public official assigned to you to report your health status.
※ Providing false information will result in criminal punishment pursuant to the Infectious Disease Control and Prevention Act.
Officer in Charge Title Name Phone number/E-mail
yy mm dd
Consulate General of
the Republic of Korea in Boston
직인Isolation Exemption Certificate
(For submission to the Quarantine Officer)
( f i l l e d b y t h e A p p l i ca n t )
Applicant information
Name Gender [ ] Male
[ ] Female
Nationality Date of birth
Passport No. Mobile phone number
(Contact information in Korea)
Status of stay
Address in Korea ※ Please provide a full address
Affiliation (Company name) Reference in Korea
(Contact information)
Last place of departure Date of departure
Flight No. Time and date of arrival
Period of visit Expected date of departure from Korea
( f i l l e d b y t h e E m b a s s y o r C o n s u l a t e )
Purpose of visit
※ △중요한 사업상(계약, 투자, 기술 지원 등) 목적, △학술적 목적(국제학술행사 등), △기타 공익적 또는 인도적 목적 등에 대한 상세 사유 적시
- 예시) 계약·투자 목적(기관명, 담당자, 계약·투자내용 등) / 학술적 목적(행사명, 주관기관 담당자, 행사일 등)
Submitted
documents ※ 초청장(초청 이메일 포함), 계약서(안), 가족관계증명서 등(여권 사본은 필히 징구)
Although the person above is subject to the Special Entry Procedure upon arrival in Korea and isolation for 14 days after the entry, the person applied for exemption from isolation for reasons as stated above. The officer in charge reviewed the request and hereby grants exemption to the applicant.
※ Isolation exemption certificate applies to foreign nationals with short-term visas (B1, B2, C1, C3, and C4) and long-term visas (D8 and D9) as well as Korean nationals.
※ You will stay in a temporary isolation facility for two days for testing. If tested negative, you will be exempt from isolation requirement.
※ In spite of this certificate, you will be isolated for treatment if tested positive.
※ You should follow the instructions of the health authority to install the Self-diagnosis App on your smartphone and report your health status everyday through the app. You will also receive a phone call on a daily basis from a public official assigned to you to report your health status.
※ Providing false information will result in criminal punishment pursuant to the Infectious Disease Control and Prevention Act.
Officer in Charge Title Name Phone number/E-mail
yy mm dd
Consulate General of
the Republic of Korea in Boston
직인Isolation Exemption Certificate (Keep for your own record)
( f i l l e d b y t h e A p p l i ca n t )
Applicant information
Name Gender [ ] Male
[ ] Female
Nationality Date of birth
Passport No. Mobile phone number
(Contact information in Korea)
Status of stay
Address in Korea ※ Please provide a full address
Affiliation (Company name) Reference in Korea
(Contact information)
Last place of departure Date of departure
Flight No. Time and date of arrival
Period of visit Expected date of departure from Korea
( f i l l e d b y t h e E m b a s s y o r C o n s u l a t e )
Purpose of visit
※ △중요한 사업상(계약, 투자, 기술 지원 등) 목적, △학술적 목적(국제학술행사 등), △기타 공익적 또는 인도적 목적 등에 대한 상세 사유 적시
- 예시) 계약·투자 목적(기관명, 담당자, 계약·투자내용 등) / 학술적 목적(행사명, 주관기관 담당자, 행사일 등)
Submitted
documents ※ 초청장(초청 이메일 포함), 계약서(안), 가족관계증명서 등(여권 사본은 필히 징구)
Although the person above is subject to the Special Entry Procedure upon arrival in Korea and isolation for 14 days after the entry, the person applied for exemption from isolation for reasons as stated above. The officer in charge reviewed the request and hereby grants exemption to the applicant.
※ Isolation exemption certificate applies to foreign nationals with short-term visas (B1, B2, C1, C3, and C4) and long-term visas (D8 and D9) as well as Korean nationals.
※ You will stay in a temporary isolation facility for two days for testing. If tested negative, you will be exempt from isolation requirement.
※ In spite of this certificate, you will be isolated for treatment if tested positive.
※ You should follow the instructions of the health authority to install the Self-diagnosis App on your smartphone and report your health status everyday through the app. You will also receive a phone call on a daily basis from a public official assigned to you to report your health status.
※ Providing false information will result in criminal punishment pursuant to the Infectious Disease Control and Prevention Act.
Officer in Charge Title Name Phone number/E-mail
yy mm dd
Consulate General of
the Republic of Korea in Boston
직인격리면제 동의서
Quarantine Exemption Agreement
1. Upon issuance and receipt of Quarantine Exemption Certificate, I agree to comply with all of the clauses specified in the certificate.
2. Upon entering the Republic of Korea, I will faithfully execute my duties for active monitoring, including but not limited to receiving a diagnostic test at the airport, installing the Self-Check application on my phone, answering phone calls from the Republic of Korea government, and notifying the relevant government authorities about my symptoms.
3. I understand and agree that my activities in the Republic of Korea will be limited only to the original intended purpose (‘important business’ or ‘public interest or humanitarian purpose’) for which my quarantine exemption application has been filed. I understand and agree that I will face immediate suspension of quarantine exemption and will be subject to self-quarantine or facility quarantine* action if I pursue any activity other than the intended purpose during my visit.
* I also understand that if I am placed under facility quarantine, I will be required to pay for the use of the facility (up to KRW 150,000 per day)
4. I understand that submitting false information on the quarantine exemption application or failing to execute my active monitoring duties will result in criminal punishment in accordance with the Infectious Disease Control and Prevention Act and agree to accept such punishment in accordance with law.
Date:
Applicant’s name:
Applicant’s signature:
To Consul General of the Republic of Korea in Boston
210㎜×297㎜[중질지(80g/㎡)]
시설격리 동의서 (영문)
시설격리 동의서
Facility Quarantine Agreement
성명
Name(姓名,氏名)
생년월일
Date of Birth(出生日期，生年月日) 국적
Nationality(国籍)
선박 ‧ 항공기명 Ship ‧ Flight No.
(船舶, 航空，航空便名) 여권번호
Passport No.
(护照号码，パスポート番号)
도착 연월일 Date of Arrival (到達日期，到着の日付)
<NOTE>
In response to the global COVID-19 outbreak, as of 00:00 April 1st, 2020 (arrival time), the Republic of Korea requires all inbound travelers to be subject to self-quarantine (Korean nationals and foreign nationals with long-term visas) or facility quarantine (foreign nationals with short-term visas).
- Foreign nationals with short-term visas: B-1, B-2, C-1, C-3, and C-4 visa holders - Foreign nationals with long-term visas: Holders of visas other than short-term visas
<ABOUT THIS FORM>
Foreign nationals with short-term visas need to complete and submit this form to the government of the Republic of Korea. If the person fails to submit this form or does not agree with all categories below, the government of the Republic of Korea may deny entry in accordance with laws including 『Immigration Act』 and 『Quarantine Act』.
<FACILITY QUARANTINE>
I, as a short-term visa holding foreign national without a Self-Quarantine Exemption Certificate, agree that I will be quarantined at a facility designated by the government of the Republic of Korea for 14 days after entry, in accordance with Article 42 of the 『Infectious Disease Control and Prevention Act』, Article 16 of the
『Quarantine Act』, etc.
□ Agree □ Disagree
<EXPENSES>
I agree to pay for the entire cost (up to KRW 2,100,000 per person) of the 14-day facility quarantine, incurred to cover the various expenses including but not limited to accommodation, meal, and transportation, upon entry to the Republic of Korea, as per the instructions of the government of the Republic of Korea.
□ Agree □ Disagree
<DEPARTURE ORDER>
I agree to accept the responsibility to comply with 14-day facility quarantine and to pay for the cost as per the instructions of the government of the Republic of Korea. I agree to unconditionally accept the actions by the government, including departure orders, that may result if I fail to comply with the instructions.
□ Agree □ Disagree
Date (MM/DD/YYYY)
Completed by
(Name) (Signature)
- 신종 코로나바이러스 감염증 (Novel Coronavirus) -
건강상태 확인서
(Health Condition Report Form)
성명(Name) 성별(Sex)
□ 남(M) □ 여(女)
국적(Nationality)
생년월일(Date of Birth)(MM/DD/YYYY)
여권번호
(Passport Number)한국 입국 예정일(Expected Date of Entry)
(MM/DD/YYYY)
본국 내 주소
(Address in Home Country)본국 내 연락처
(Phone Number in Home Country)한국 내 주소
(Address in Korea)한국 내 연락처
(Phone Number in Korea)최근 30일 동안 체류한 도시를 모두 적으시오.
Please list all cities you have stayed within 30 days prior to application.
1) 2) 3) 4) 5)
최근 14일 이내에 후베이(湖北) 전역 또는 우한(武漢)에 방문 또는 체류한 사실이 있습니까?
Have you visited or stayed in Hubei or Wuhan, China within 14 days prior to application?
[ ]예(Yes) [ ]아니오(No)
최근 14일 동안에 아래 증상이 있었거나 현재 있는 경우 해당란에 "√" 표시를 하십시오.
Please mark any of the following symptoms you currently have or have experienced in the last 14 days [ ]발열(
Fever)[ ]오한(
Chills)[ ]두통(
Headache)[ ]인후통
(
Sore throat)[ ]콧물 (
Runny nose)[ ]기침(
Cough) [ ]호흡곤란
(
Shortness of breath)[ ]구토(
Vomiting)[ ]복통 또는 설사
(
Abdominal pain or Diarrhea)[ ]발진(
Rash)[ ]황달(
Jaundice)[ ]의식저하 (L
oss of consciousness)[ ]점막 지속 출혈 (
Bloody mucus) * 눈, 코, 입 등(*Eyes, nose, mouth, etc.)
[ ]그 밖의 증상(
Other symptoms)( )
위의 증상 중 해당하는 증상이 있는 경우에는 아래 항목 중 해당란에 "√" 표시를 하십시오.
If you marked any of the above symptoms, please mark all of the following that apply.
[ ] 증상 관련 약 복용 중 (M
edication taken for symptoms)[ ] 병원 치료·진료를 받음
(Undergone diagnosis or medical care) 해당 증상이 없는 경우에는 우측 "증상 없음"란에 "√" 표시를 하십시오.
(
If none of the symptoms apply, please mark the "No Symptoms" box.)[ ] 증상 없음 (
No Symptoms)본 확인서 작성을 기피하거나 거짓으로 작성하여 제출하는 경우 「출입국관리법」에 따라 사증 발급 또는 입국이 거부되거나 체류가 제한될 수 있습니다.
Making false statements concerning your health or failing to fill out the form may result in a denial of visa, entry into or permission of stay in the ROK in accordance with the Imm igration Act of the Republic of Korea.
작성인은 위 건강상태 질문서를 사실대로 작성하였음을 확인합니다.
I confirm that the information provided above is true and correct.
Date (MM/DD/YYYY)
Applicant (Signature)
주보스턴대한민국총영사관 귀하
Consulate General of the Republic of Korea in Boston
Copy of Passport
(Original should be presented at Consulate General)
Information for Travelers with the Isolation Exemption Certificate
□ All travelers (both Korean- and foreign-nationals) entering Korea with the Isolation Exemption Certificate issued by the Embassy (or Consulate) of the Republic of Korea should follow the following instructions when entering Korea, to prevent the spread of COVID-19.
① All travelers shall have the Isolation Exemption Certificate issued by the Embassy or Consulate before the departure of flight and present the Certificate at the immigration office.
- All travelers shall wear the pass (yellow or green) given at the immigration office around their neck and move to the screening clinic or temporary residential facility following staff instructions.
② All travelers shall be tested for COVID-19 immediately after entry, at a screening clinic in the airport (9:00 ～19:00) or Living and Treatment Support Center (19:00 ～9:00). Before the test results are confirmed, they shall wait at a designated temporary residential facility*.
* When entering the facility, travelers shall complete a form following staff instructions and wait in the assigned room. Travelers shall be allowed to move to their residence in Korea only if they are tested negative.
③ Travelers should install the Self-Diagnosis Mobile App (Ministry of Health and Welfare) and record their health status (symptoms such as fever, cough, sore throat, and dyspnea) for 14 days from the day after entry.
Self-Diagnosis App
QR
Code URL
