Self Declaration to Travel to Goa

**In case any Goan citizen requires travel assistance to return to Goa, then select the
service "Registration for Goans returning from other States of India".

Applicant Name*

Vinayak Badaskar
Father/Husband*

Krishna

Mobile No*

7892034645
Email ID

vinayakbr@gmail.com

Residence Address in Goa*

Mother Teresa Old age home, behind Glenmark company, near Powergrid of India, Colvale

Residence Taluka in Goa*

Bardez

Purpose of your travel*

Others
Please mention other purpose*

Site Visit

Entry Date*

30-Jul-2020

Vehicle Registration No. Which you intend to use to commute*

SPACE AND SPECIAL CHARACTERS NOT ALLOWED

Travel from location*

Belgaum
To Location*
 Mapusa

From State*

Karnataka
To State*

GOA
Entering Goa State via Checkpost*

Keri(Sattari) Checkpost

Driver Details (Only if travelling by road)

Driver name*

Kiran Bedka
Staying/Returning*

Returning
Age*

40
Symptoms*

No Symptoms

Details of the cities/countries visited in last 28 days*

None
Su ering from*

None of the above

Other Travellers who are travelling with the Vehicle Driver (Co-Traveller Details)

Name*

Name
Staying/Returning*

Select...
Age*

Symptoms*

Select...

Details of the cities/countries visited in last 28 days*

Su ering from*

Select...

Add

Name Staying/Returning

Kiran Agasgekar Returning

✏ 

Driver and co-traveller have to submit declaration at checkpost. The declaration will
be available for download and print once you submit this form.

Select (✔) any option

We opt to undergo COVID-19 test by paying Rs. 2000/- on arrival in Goa

If opted for COVID-19 testing on arrival in Goa, testing will be done at suitable location and
therea er, you have to maintain self-isolation till test results are out.

We opt to be strictly Home Quarantined for 14 days on arrival in Goa

If opted for home quarantine, you have to maintain regular contact with the local
PHC/CHC and immediately intimate them in case of any occurance of symptoms. The
home quarantine protocol should be followed strictly and any violation will result in you
being shi ed to institutional quarantine.

I/we have a COVID-19 negative test report from a ICMR approved testing facility taken in
last 48 hours (copy of the same to be produced at the checkpost)

Declaration*
1) I agree that all the above information is true to the best of my knowledge.
2) I/We have downloaded the Aarogya Setu app and before starting the journey I/we
have confirmed my/our status as "safe"

Proceed to Document Upload

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