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Self Declaration Form Details For International Arriving Passengers

The document contains a self declaration form for international arriving passengers with fields for passenger details like name, passport number, flight details, contact information, health details, cities visited and a declaration agreeing to follow quarantine guidelines.

Uploaded by

Koteswar Mandava
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65 views2 pages

Self Declaration Form Details For International Arriving Passengers

The document contains a self declaration form for international arriving passengers with fields for passenger details like name, passport number, flight details, contact information, health details, cities visited and a declaration agreeing to follow quarantine guidelines.

Uploaded by

Koteswar Mandava
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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
@
SR2108150209615

Name Date of Birth


ARJUN KUMAR RAM 06/04/1985

Flight Number Seat Number


J91409 DNK

PNR Number Nationality


HY62UQ INDIA

Passport Number Passport Copy Uploaded


S5886775 No

Date of Arrival Country of Origin


17/08/2021 KUWAIT

Are you taking a connecting Domestic flight? Domestic Connecting Flight


NO

RT-PCR Negative Certificate Uploaded


Yes

City of Origin First Airport of Entry


KUWAIT DELHI AIRPORT

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


NEW DELHI SHER

Final Destination Street/Village Final Destination Tehsil


SIDHWALIYA GOPALGANJ

Final Destination State/Union Territories Final Destination District/City


BIHAR GOPALGANJ

Final Destination Pincode Contact Number


841407 +919006378705

Alternate Contact Number Email ID


DEEPTHI@[Link]

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?
NO 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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