Strona 1 Signed by / MEDICAL CERTIFICATE ON SARS-COV-2 RT-PCR TESTING RESULT Podpisano przez: Tomasz Piotr ORDER: 1175508221 Anyszek Date / Data: 2021-05-30 02:20 SURNAME PILECKA NAME ZOFIA DATE OF BIRTH 09.10.2002 PLACE OF BIRTH KRAKÓW TYPE OF IDENTITY DOCUMENT PASSPORT NUMBER OF IDENTITY DOCUMENT ET8184798 WAS TESTED FOR SARS-COV-2 ON (DATE) 29.05.2021 21:33:13 SARS-COV-2 RT-PCR TESTING RESULT POSITIVE NEGATIVE DATE: 29.05.2021 SIGNATURE OF A CERTIFYING PHYSICIAN TOMASZ ANYSZEK (7770597) Document with an electronic signature