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

@

SR2104010012581

Name Date of Birth

RAVINDER SINGH 10/02/1977

Flight Number Seat Number

QR1416 26A

PNR Number Nationality

INDIA

Passport Number Passport Copy Uploaded

N8982707 Yes

Date of Arrival Country of Origin

03/04/2021 NIGERIA

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

BHARI AMRITSAR AIRPORT

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

PUNJAB 235

Final Destination Street/Village Final Destination Tehsil

BHARI KHAMANO

Final Destination State/Union Territories Final Destination District/City

PUNJAB FATEHGARH SAHIB

Final Destination Pincode Contact Number

141411 +919*********

Alternate Contact Number Email ID

+919********* adlk8f@r.postjobfree.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.

Contact this candidate