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    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    Abhinav Verma
    This document contains a self declaration form for international arriving passengers with fields for passenger details, travel history, health symptoms, and agreement to terms. The form asks for name, passport, flight and travel details, health symptoms, and agreement to follow quarantine guidelines.

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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

    Abhinav Verma
    15 views2 pages
    This document contains a self declaration form for international arriving passengers with fields for passenger details, travel history, health symptoms, and agreement to terms. The form asks for name, passport, flight and travel details, health symptoms, and agreement to follow quarantine guidelines.

    Original Title

    SR2110160408790

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    This document contains a self declaration form for international arriving passengers with fields for passenger details, travel history, health symptoms, and agreement to terms. The form asks for name, passport, flight and travel details, health symptoms, and agreement to follow quarantine guidelines.

    Copyright:

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

    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    Abhinav Verma
    This document contains a self declaration form for international arriving passengers with fields for passenger details, travel history, health symptoms, and agreement to terms. The form asks for name, passport, flight and travel details, health symptoms, and agreement to follow quarantine guidelines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 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
    @
    SR2110160408790

    Name Date of Birth


    KUMAR ABHINAV 28/09/1993

    Flight Number Seat Number


    AF226 NA

    PNR Number Nationality


    PRXSZN INDIA

    Passport Number Passport Copy Uploaded


    N3513487 Yes

    Date of Arrival Country of Origin


    16/10/2021 FRANCE

    Are you taking a connecting Domestic flight? Domestic Connecting Flight


    YES LUCKNO

    RT-PCR Negative Certificate Uploaded


    Yes

    City of Origin First Airport of Entry


    PARIS DELHI AIRPORT

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


    NEW DELHI 613/P49

    Final Destination Street/Village Final Destination Tehsil


    NEAR EK NATH MANDIR SITAPUR ROAD

    Final Destination State/Union Territories Final Destination District/City


    UTTAR PRADESH LUCKNOW

    Final Destination Pincode Contact Number


    226020 +919453845329

    Alternate Contact Number Email ID


    +917355591132 ABHINAV28SEP@GMAIL.COM

    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?
    BELGIUM 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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