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    SR2107180241652 3

    Uploaded by

    Mayank Kumar
    This self-declaration form provides details for an international arriving passenger named Rattan Sharma from Uruguay to India. The form includes personal details like name, date of birth, passport and contact information. It also includes flight details, COVID test results, domestic travel plans within India, health details and a declaration agreeing to follow quarantine guidelines.

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

    SR2107180241652 3

    Uploaded by

    Mayank Kumar
    17 views2 pages
    This self-declaration form provides details for an international arriving passenger named Rattan Sharma from Uruguay to India. The form includes personal details like name, date of birth, passport and contact information. It also includes flight details, COVID test results, domestic travel plans within India, health details and a declaration agreeing to follow quarantine guidelines.

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    Duejn

    Original Title

    SR2107180241652-3

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    This self-declaration form provides details for an international arriving passenger named Rattan Sharma from Uruguay to India. The form includes personal details like name, date of birth, passport and contact information. It also includes flight details, COVID test results, domestic travel plans within India, health details and a declaration agreeing to follow quarantine guidelines.

    Copyright:

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

    SR2107180241652 3

    Uploaded by

    Mayank Kumar
    This self-declaration form provides details for an international arriving passenger named Rattan Sharma from Uruguay to India. The form includes personal details like name, date of birth, passport and contact information. It also includes flight details, COVID test results, domestic travel plans within India, health details and a declaration agreeing to follow quarantine guidelines.

    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

    T PASSENGER DETAILS

    Registration Number
    @
    SR2107180241652

    Name Date of Birth


    RATTAN SHARMA 02/01/1961

    Flight Number Seat Number


    QR578 5A

    PNR Number Nationality


    6B85TI INDIA

    Passport Number Passport Copy Uploaded


    Z6124561 Yes

    Date of Arrival Country of Origin


    20/07/2021 URUGUAY

    Are you taking a connecting Domestic flight? Domestic Connecting Flight


    YES 6E2042

    RT-PCR Negative Certificate Uploaded


    Yes

    City of Origin First Airport of Entry


    URUGUAY DELHI AIRPORT

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


    NEW DELHI 2B, GANPATI APAR

    Final Destination Street/Village Final Destination Tehsil


    STREET NO 7, DEHRADUN DEHRADUN

    Final Destination State/Union Territories Final Destination District/City


    UTTARAKHAND DEHRADUN

    Final Destination Pincode Contact Number


    248001 +919820203589

    Alternate Contact Number Email ID


    +919819352961 [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?
    URUGUAY 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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