Certificate of Compliance

TO VERMONT BE SMART, STAY SAFE EXECUTIVE ORDER 01-20 (6/19/20 version)

Please understand and complete the following form as required by the State of Vermont before your stay with us. Every item requires either a value or a click to the leading checkbox indicating you’ve read that item.

If you prefer to complete the PDF and send or deliver it to us, you may download the form here. All details will be kept on file for 30 days and may be shared with the State of Vermont Government, should they request it of us.

    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 have been in a county in NY, RI, MA, ME, NH, or CT with fewer 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, and I will complete 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, and I acknowledge that I must stay in my quarantine location for the duration of the quarantine.

    2. I also certify that 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°F/38°C);
    • Used a fever reducer (in the past 24 hours, have you used any medicine that reduces fevers?);
    • 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 a list of the names of all such persons in your care.



    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 reviewed the State of Vermont out-of-state traveler guidelines and travel map and comply with current health and safety requirements for traveling to, from, and within the State of Vermont. I further certify that I understand all travelers should stay home if ill (with any symptoms); maintain physical distance of at least 6’ from anyone outside their household; wear a cloth mask when in public spaces; and wash or sanitize hands often.

    7. I have read and understand this entire Certificate of Compliance and make the above certifications under the pains and penalties of perjury.

    By checking this box:
    and typing my name below, I agree that all of the information I've provided on this form is true and accurate.


    This form is sent to susan@VacationRentalsInVermont.com. A copy will also be sent to your email.

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