COVID-19 Certificate of Compliance

COVID-19 Certificate of Compliance
1. I certify that:

I am a critical worker as defined by the State of Vermont; ORI have not left the state of Vermont for any reason except essential travel in the past 14 days; ORI reside in a county with less than 400 active COVID-19 cases per million, as set forth on the Vermont Agency of Commerce and Community Development's website*, and I did not travel to Vermont by air or bus; ORI have traveled to Vermont from another state, and I traveled directly from my home in my personal vehicle, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in that state; ORI have traveled to Vermont from another state to sell or purchase property, and I have completed a 14-day self-quarantine (or a 7-day self-quarantine followed by a negative test result) in Vermont at a lodging establishment or residence.I am a non-Vermont resident who has a fully signed and accepted Purchase and Sale Contract to purchase a property and I am traveling to see that property.
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 do not currently, 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 degrees F/38 degrees C)
- Used a fevera reducer (in the past 24 hours, have you used any medicine that reduces fever?)
- Chills
- Repeated shaking with chills
- Muscle pain
- Headache
- Sore throat
- New loss of taste or smell
4. 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 the names of all such persons in your care below.
Name: Name:
Name: Name:
Name: Name:
Name: Name:
5. 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.
6. I certify that I have read and answered the above questions truthfully and to the best of my knowledge. I am aware of the potential risks associated with viewing/showing the real property located at the address(es) below and hold Century 21 Farm & Forest, including its owners, employees, agents, brokers and any affiliated companies harmless and release them from any and all claims, actions, complaints or the like related to any exposure to COVID-19.
Street Address Town
Street Address Town
Street Address Town
Street Address Town
While viewing properties, it is recommended that all parties wear face masks, as well as gloves. If you choose to not wear gloves, we ask that you refrain from touching surfaces when touring homes.
* For information related to completing this form, visit: accd.vermont.gov/covid-19/restart/cross-state-travel
Date: in Vermont
Name

First NameLast Name
Signature

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Household Contact Information:
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