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

SR2205150679820 22/09/1993

Name Seat Number

EBIN KUNNATH BABY 22A

Flight Number Nationality

QRO536 INDIA

PNR Number Passport Copy Uploaded

LDUUOQ Yes

Passport Number Country of Origin

K3065959 DENMARK

Date of Arrival Domestic Connecting Flight

16/05/2022

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

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

No 12/11/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes CALICUT AIRPORT

City of Origin Final Destination - House Number

COPENHAGEN KUNNATH HOUSE

First Airport of Entry State/Union Territories Final Destination Tehsil

KERALA KURUMBALANGODE

Final Destination Street/Village Final Destination District/City

ERUMAMUNDA MALAPPURAM

Final Destination State/Union Territories Contact Number

KERALA +919995781615

Final Destination Pincode Email ID

679334 EBIN123KUNNATH@GMAIL.COM

Alternate Contact Number Diabetes

+919497343734 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? Location of Final Vaccination dose
DENMARK India

Are you being evacuated from Ukraine by the Ministry of How many passengers are travelling?
External Affairs?
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.