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
@
SR2107230310997

Name Date of Birth

AJMEER ALI ZADIQ ALI 19/10/1979

Flight Number Seat Number

IX623 DNK

PNR Number Nationality

GVKEYL INDIA

Passport Number Passport Copy Uploaded

Z4678303 Yes

Date of Arrival Country of Origin

24/07/2021 MALAYSIA

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

KUALA LUMPUR TRICHY AIRPORT

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

TAMIL NADU 112

Final Destination Street/Village Final Destination Tehsil

MANIVILAN 7TH STREET ARANTHANGI

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU PUDUKOTTAI

Final Destination Pincode Contact Number

614616 +91162929099

Alternate Contact Number Email ID

IMRANZAP@HOTMAIL.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?
MALAYSIA 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.