Declaration of Travel History of seafarer (past 28 days) Annexure - I

Name
Last sign off Date Indos No.
Last sign off Port/ Country Pasport No.

Approx. time of Name of the person(s)

S. No. Date Details / address of place visited (Home, Friend, Hotel, Social gathering, Hospitals etc.) visit to you met Contact details (phone no.) of
place(s) Hrs with person(s) met

1
2
3
4
5
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7
8
9
10
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12
13
14
15
16
17
18
19
20

I / we, do hereby declare that above particulars of information and facts stated are true, correct and complete to the best of my knowledge and belief.

Place:
Date: Name / Sign.