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
SR2212310004597

Name Flight Number

NAVEEN KAPOOR SQ406

Nationality Passport Number

AUSTRALIA PB2220127

Date of Arrival Country of Departure ( Origin )

01/01/2023 SINGAPORE

Date of RT-PCR Test Taken RT-PCR Negative Certificate Upload

30/12/2022 YES

First Airport of Entry Final Destination Address

DELHI AIRPORT H NO 1933 A , RAJPURA TOWN

Final Destination State/Union Territories Final Destination District/City

PUNJAB PATIALA

Final Destination Pincode Mobile Number

140401 +919815508408

Email ID Details of the Countries visited in last 14

days?
NAVEENKAPOOR.21@GMAIL.COM AUSTRALIA, SINGAPORE

How many passengers are travelling with you in the same flight and to the same final destination?
3

CO PASSENGER DETAILS

Passenger 2

Name Flight Number

MONIKA KAPOOR SQ406

Nationality Passport Number

AUSTRALIA PB5464120

Date of Arrival Country of Departure ( Origin )

01/01/2023 SINGAPORE
Is the passenger less than 12 years of age? Date of Birth
NO -

Date of RT-PCR Test Taken Date of RT-PCR Test Taken

30/12/2022 YES

First Airport of Entry Final Destination Address

DELHI AIRPORT H NO 1933 A , RAJPURA TOWN

Final Destination State/Union Territories Final Destination District/City

PUNJAB PATIALA

Final Destination Pincode Mobile Number

140401 +919815508408

Email ID Details of the Countries visited in last 14

days?
NAVEENKAPOOR.21@GMAIL.COM AUSTRALIA, SINGAPORE

Passenger 3

Name Flight Number

YUVRAJ KAPOOR SQ406

Nationality Passport Number

AUSTRALIA PB5836995

Date of Arrival Country of Departure ( Origin )

01/01/2023 SINGAPORE

Is the passenger less than 12 years of age? Date of Birth

NO -

Date of RT-PCR Test Taken Date of RT-PCR Test Taken

30/12/2022 YES

First Airport of Entry Final Destination Address

DELHI AIRPORT H NO 1933 A , RAJPURA TOWN

Final Destination State/Union Territories Final Destination District/City

PUNJAB PATIALA

Final Destination Pincode Mobile Number

140401 +919815508408

Email ID Details of the Countries visited in last 14

days?
NAVEENKAPOOR.21@GMAIL.COM AUSTRALIA, SINGAPORE

Passenger 4

Name Flight Number

PRANSHI KAPOOR SQ406
 Nationality Passport Number
AUSTRALIA PB5836996

Date of Arrival Country of Departure ( Origin )

01/01/2023 SINGAPORE

Is the passenger less than 12 years of age? Date of Birth

YES 08/12/2012

Date of RT-PCR Test Taken Date of RT-PCR Test Taken

- NO

First Airport of Entry Final Destination Address

DELHI AIRPORT H NO 1933 A , RAJPURA TOWN

Final Destination State/Union Territories Final Destination District/City

PUNJAB PATIALA

Final Destination Pincode Mobile Number

140401 +919815508408

Email ID Details of the Countries visited in last 14

days?
NAVEENKAPOOR.21@GMAIL.COM AUSTRALIA, SINGAPORE

I/We have agreed to the following terms:

I agree to the guidelines issued by Ministry of Health & Family Welfare.
I undertake to quarantine/self monitor/take the self paid Covid-19 test on arrival as applicable to me as per the latest
MOHFW guidelines.
I, the primary applicant/passenger, authorise to be contacted by the Ministry of Health and Family Welfare, Government
of India, for the purpose of identification and related checks of my co-passenger(s), if required. In case of any default, the
primary applicant will be liable for punishable offences under the provisions of the relevant Indian Laws. I also agree to
the terms & conditions.
I, the primary applicant, certify that the information filled is correct and true.
For latest travel advisory kindly visit the link, https://www.newdelhiairport.in/covid19