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 V

Registration Number Date of Birth

SR2111110342877 23/01/1983

Name Seat Number

TASNEEM FARHANA 1B

Flight Number Nationality

IX914 INDIA

PNR Number Passport Copy Uploaded

1A2IX7 Yes

Passport Number Country of Origin

R1611803 OMAN

Date of Arrival Domestic Connecting Flight

12/11/2021

Are you taking a connecting Domestic flight? Date of RT-PCR Test Taken
NO 10/11/2021

RT-PCR Negative Certificate Uploaded Date of Final Dose of Vaccination

Yes 13/10/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes HYDERABAD AIRPORT

City of Origin Final Destination - House Number

MUSCAT PLOT NO. 351

First Airport of Entry State/Union Territories Final Destination Tehsil

TELANGANA SHAHEEN NAGAR

Final Destination Street/Village Final Destination District/City

SHAHEEN NAGAR HYDERABAD

Final Destination State/Union Territories Contact Number

TELANGANA +917386278562

Final Destination Pincode Email ID

500005 DRFATIMAALSAADI@GMAIL.COM

Alternate Contact Number Diabetes

+919581219950 No
 Fever Hypertension
No No

Cough Bronchial Asthma

No No

Respiratory Distress Cancer

No No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
NONE 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.