This is to certify that …………………………… date of birth

sex …………………………………..whose signature follows-

has on the date indicated been vaccinated or revaccinated against smallpox with a freeze-dried or liquid vaccine certified to fulfill the recommended requirements of the World Health Organization.

The validity of this certificate shall extend for a period of three years, beginning eight days after the date of a successful primary vaccination or, in the event of a revaccination, on the date of that revaccination.

The approved stamp mentioned above must be in a form prescribed by the health administration of the territory in which the vaccination is performed.

This certificate must be signed by a medical practitioner in his own hand; his official stamp is not an accepted substitute for the signature.

Any amendment of this certificate, or erasure, or failure to complete any part of it, may render it invalid.