General ICAO ANNEX 9

APPENDIX 1
Declaration

(OUTWARD/INWARD)

Operator Batik Air Aircraft

Marks of Nationality and Registration PK-LBZ Flight ID 7283 Date 11/11/2023

Departure from KUL (KUALA LUMPUR INTL SEPANG) Arrival at CGK (JAKARTA SOEKARNO HATTA INTL)

FLIGHT ROUTING
(*Airport:* Column always to list origin, every en-routing stop and destination)
Passport No. Of Passengers
Port ID Name Pax Pos Passport Birth Date G Ntly
Expiry on this stage
KUL 52073052 DENNY DERMAWAN PIC CPT X1716646 17/10/77 M 10/06/27 Departure Place:

CGK 212302 ARGA WIJAYA PUTRA FO C7098658 27/04/00 M 03/09/25

170233 DWITA ARYUDHANI SFA C6953777 30/09/93 F 02/11/25 Embarking:

220407 NI WAYAN JUITA ASMARA FA X1020513 21/07/91 F 19/06/25

Through on same
231272 ANDRE JAMAL ARDIANSYAH FA C9055406 05/03/96 M 28/04/27
flight:
231282 MELEGI STAR DENDI NUH FA E0557268 30/07/99 F 29/08/27

231766 DILA EKA PUTRI FA E0687347 13/12/00 F 13/09/27 Arrival Place:

Disembarking:

Through on same
flight:

DECLARATION OF HEALTH FOR OFFICIAL USE ONLY

Name and seat number or function of persons on board with illnesses other than airsicknesses or the effects of
accidents, who may be suffering from a communicable disease ( a fever- temperature 38øC/100øF or greater-
associated with one or more or the following signs or symptoms, e.g. appearing obviously unwell;persistent
coughing;persistent vomiting;skin rash; bruising or bleeding without previous injury; or confusion of recent onset,
increases the likelihood that the person is suffering a communicable disease) as well as such cases of illness
disembarked during a previous stop .............................................................................................................................

Details of each disincecting or sanitary treatment(place, date, time, method) during the flight. If no dinsecting has been
carried out during the flight,give details of most recent disinsecting ..................................................................

Signed, if required, with time and date

Crew member concerned

I declare that all statements and particulars contained in this General Declaration and in any supplementary forms required to be presented with
this General Declaration are complete exact and true to the best of my knowledge and that all through passengers will continue/have continued
on the flight.

Signature
Authorized Agent or Pilot-In-Command
Delete as necessary

REMARKS: