State of Texas

Form for Arrivals from Areas Designated for Mandatory Self-Quarantine

Pursuant to the Texas Governor’s Executive Order GA-11, dated March 26, 2020, persons entering the
State of Texas as a final destination from designated areas must self-quarantine for 14 days or the
duration of presence in Texas, whichever is shorter, and must provide the following information:

Name: ________________ ________________ ________________

First Middle Last

Date of Birth: ________________ ________________ ________________

Month Day Year

Flight Information: ________________ ________________

Flight Number Airline

Driver License or Passport: _________________________________ _________________

Number Issuing State or Country

Telephone Number while in Texas: ____________________________________________________

Home Address: ____________________________________________________

Street Address
____________________________________________________
City, State or Country, Postal Code

A covered person under Executive Order GA-11 must designate a quarantine location in Texas, such as a
residence or a hotel, and then self-quarantine at that location. Mandatory terms can be found at
www.dps.texas.gov/COVIDtravel. Under Texas Government Code § 418.173, failure to comply is a
criminal offense punishable by a fine of up to $1,000, confinement in jail for up to 180 days, or both.

Designated Quarantine Location:

___________________________________________________
Street Address

___________________________________________________
City, State, Postal Code

I certify that this information is correct and complete to the best of my knowledge, and I
understand that providing false information on this form is a criminal offense under Texas Penal
Code § 37.10.

Signature: _______________________________