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
@
SR2104180394072

Name Date of Birth

MOHAMMED ALI 17/12/1989

Flight Number Seat Number

G9458 Y

PNR Number Nationality

66761347 INDIA

Passport Number Passport Copy Uploaded

N1953022 Yes

Date of Arrival Country of Origin

19/04/2021 UNITED ARAB EMIRATES

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

HYDERABAD HYDERABAD AIRPORT

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

TELANGANA 6-7-122

Final Destination Street/Village Final Destination Tehsil

INDRA NAGAR ,HASSAN NAGER RAJENDER NAGER

Final Destination State/Union Territories Final Destination District/City

TELANGANA HYDERABAD

Final Destination Pincode Contact Number

500052 +919347029220

Alternate Contact Number Email ID

+919866754228 ANAS48763.ALI@GMAIL.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?
UAE,DUBAI 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.