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    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    roselin sahayam
    This self-declaration form summarizes a passenger's travel details arriving internationally into India. It includes information such as the passenger's name, date of birth, flight details, contact information, health details like symptoms and medical history, places visited in the last 14 days, and an agreement to follow Ministry of Health guidelines including quarantining and testing.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    roselin sahayam
    57 views2 pages
    This self-declaration form summarizes a passenger's travel details arriving internationally into India. It includes information such as the passenger's name, date of birth, flight details, contact information, health details like symptoms and medical history, places visited in the last 14 days, and an agreement to follow Ministry of Health guidelines including quarantining and testing.

    Original Title

    Suresh AS

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    This self-declaration form summarizes a passenger's travel details arriving internationally into India. It includes information such as the passenger's name, date of birth, flight details, contact information, health details like symptoms and medical history, places visited in the last 14 days, and an agreement to follow Ministry of Health guidelines including quarantining and testing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    57 views2 pages

    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    roselin sahayam
    This self-declaration form summarizes a passenger's travel details arriving internationally into India. It includes information such as the passenger's name, date of birth, flight details, contact information, health details like symptoms and medical history, places visited in the last 14 days, and an agreement to follow Ministry of Health guidelines including quarantining and testing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Self Declaration form details for international arriving passengers

    Applications are being accepted on behalf of the Ministry of Health and Family Welfare, Government of India

    PASSENGER DETAILS

    Registration Number
    @
    SR2104140300851

    Name Date of Birth


    SURESH 24/07/1992

    Flight Number Seat Number


    FZ8515 23K

    PNR Number Nationality


    R0VPR2 INDIA

    Passport Number Passport Copy Uploaded


    T8821603 Yes

    Date of Arrival Country of Origin


    15/04/2021 SOUTH SUDAN

    Are you taking a connecting Domestic flight? Domestic Connecting Flight


    NO

    RT-PCR Negative Certificate Uploaded


    Yes

    City of Origin First Airport of Entry


    JUBA CHENNAI AIRPORT

    First Airport of Entry State/Union Territories Final Destination - House Number


    TAMIL NADU HILL TOP

    Final Destination Street/Village Final Destination Tehsil


    KANCHEEPURAM

    Final Destination State/Union Territories Final Destination District/City


    TAMIL NADU KANCHEEPURAM

    Final Destination Pincode Contact Number


    600016 +919585541105

    Alternate Contact Number Email ID


    +919585541104 [email protected]

    Fever Diabetes
    No No
    Cough Hypertension
    No No

    Respiratory Distress Bronchial Asthma


    No No

    Cancer
    No

    Unde Immunosuppresive Therapy


    No

    Post Transplant Patients


    No

    Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
    NIL 1

    I/We have agreed to the following terms:

    I agree to the guidelines issued by Ministry of Health & Family Welfare.

    The above information is correct and in case of any wrong information and non-cooperation, I will be liable for action
    under the law. I also agree to the terms & conditions.

    I undertake to quarantine/self monitor/take the self paid RTPCR test on arrival as applicable to me as per the latest
    MOHFW guidelines.

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