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    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    Lala Kamarudheen
    The self declaration form collects passenger details like name, passport information, flight details, health symptoms, countries visited, and agreement to follow quarantine guidelines; it is submitted to the Ministry of Health and Family Welfare for international arriving passengers entering India.

    Copyright:

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

    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    Lala Kamarudheen
    171 views2 pages
    The self declaration form collects passenger details like name, passport information, flight details, health symptoms, countries visited, and agreement to follow quarantine guidelines; it is submitted to the Ministry of Health and Family Welfare for international arriving passengers entering India.

    Original Title

    SR2104170371616

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    The self declaration form collects passenger details like name, passport information, flight details, health symptoms, countries visited, and agreement to follow quarantine guidelines; it is submitted to the Ministry of Health and Family Welfare for international arriving passengers entering India.

    Copyright:

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

    Self Declaration Form Details For International Arriving Passengers

    Uploaded by

    Lala Kamarudheen
    The self declaration form collects passenger details like name, passport information, flight details, health symptoms, countries visited, and agreement to follow quarantine guidelines; it is submitted to the Ministry of Health and Family Welfare for international arriving passengers entering India.

    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
    @
    SR2104170371616

    Name Date of Birth


    SHARMA DEVENDRA KUMAR 03/01/1973

    Flight Number Seat Number


    A1940 22C

    PNR Number Nationality


    INDIA

    Passport Number Passport Copy Uploaded


    N9411205 Yes

    Date of Arrival Country of Origin


    18/04/2021 BAHRAIN

    Are you taking a connecting Domestic flight? Domestic Connecting Flight


    YES A19809

    RT-PCR Negative Certificate Uploaded


    Yes

    City of Origin First Airport of Entry


    DEORIA DELHI AIRPORT

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


    NEW DELHI GORAKPUR

    Final Destination Street/Village Final Destination Tehsil


    KORAYA GORAKPUR

    Final Destination State/Union Territories Final Destination District/City


    UTTAR PRADESH DEORIA

    Final Destination Pincode Contact Number


    274182 +919695031525

    Alternate Contact Number Email ID


    +919695031525 HSEOFFICERLALA@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?
    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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