Tuesday, March 17, 2020



En application de l’article 1er du décret du 16 mars 2020 portant réglementation des
déplacements dans le cadre de la lutte contre la propagation du virus Covid-19 :

Je soussigné(e)
Mme / M.
Né(e) le :
Demeurant :

certifie que mon déplacement est lié au motif suivant (cocher la case) autorisé par
l’article 1er du décret du 16 mars 2020 portant réglementation des déplacements dans
le cadre de la lutte contre la propagation du virus Covid-19 :

déplacements entre le domicile et le lieu d’exercice de l’activité professionnelle,
lorsqu’ils sont indispensables à l’exercice d’activités ne pouvant être organisées
sous forme de télétravail (sur justificatif permanent) ou déplacements
professionnels ne pouvant être différés ;

déplacements pour effectuer des achats de première nécessité dans des
établissements autorisés (liste sur gouvernement.fr) ;

déplacements pour motif de santé ;

déplacements pour motif familial impérieux, pour l’assistance aux personnes
vulnérables ou la garde d’enfants ;

déplacements brefs, à proximité du domicile, liés à l’activité physique individuelle
des personnes, à l’exclusion de toute pratique sportive collective, et aux besoins
des animaux de compagnie.

Fait à ................................., le......../......../2020


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