Thank you for using the SG Arrival Card!

This SG Arrival Card is only valid for one time use for travel on the
expected date of arrival indicated below. You may choose to download or print a copy of this acknowledgement
and retain it for the duration of your stay. Please note that the SG Arrival Card is not a visa. The use of the SG
Arrival Card e-Service is free of charge.

The unauthorised consumption, possession, import, export and/or trafficking of any controlled drug is an offence
under Singapore's Misuse of Drugs Act . Under the Act, drug trafficking is punishable by death.

Providing false health and travel declarations is an offence under Section 64(b) of Singapore's Infectious Diseases
Act. The penalty for providing false or misleading information is a fine of up to S$10,000 and/or imprisonment of
up to 6 months. For subsequent offence(s), the penalty is a fine up to S$20,000 and/or imprisonment of up to 12
months. You are reminded that it is your responsibility to update and resubmit your declarations prior to your
arrival in Singapore if you had contact with a COVID-19 case, and/or if there is any change in your health status
and/or travel history.

You are required by law to give a report using Form NP 727/A/B/C if the total value of currency and/or bearer
negotiable instruments you are carrying exceeds SGD 20,000 (or equivalent in a foreign currency).

If you are bringing in any item, or carrying an item for someone else, but you do not know what it contains, you
must declare the item at the Red Channel.

You can refer to the ICA website at Entering and Departing Singapore (https://www.ica.gov.sg/enter-depart) for
more information on Singapore's entry requirements and the list of prohibited or controlled items.

Transaction Date: 21/12/2022 01:13 PM (Singapore Time)

Trip 1 Date of Arrival to Singapore 21/12/2022

DE Number Full Name (In Passport) Passport Number

Z3888Q6415 ADITIA SUGIARTO PRAYITNO X1324287
DE Number: Z3888Q6415 VG

Personal Information
Full Name (In Passport)
ADITIA SUGIARTO PRAYITNO

Sex Date of Birth

MALE 17/06/1983
Place of Residence
INDONESIA, EAST JAVA, SURABAYA

Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
X1324287 23/03/2027
Mobile Number Email Address
+62 82219199191 ADI_DOT@YAHOO.COM

Trip Information and Declaration

Trip Information
Date of Arrival to Singapore Date of Departure From Singapore
21/12/2022 30/12/2022
Mode of Travel
AIR
Mode of Travel (Details) Flight Number
COMMERCIAL JETSTAR AIRWAYS INTERNATIONAL (JQ) 3K248
Type of Accommodation in Singapore
RESIDENTIAL
Street Name Postal Code Block Number
WILBY ROAD 276307 24
Building Name Unit Number Floor Number
TESSARINA 1033 01
Last City / Port of Embarkation Before Singapore
INDONESIA, EAST JAVA, SURABAYA
Next City / Port of Disembarkation After Singapore
INDONESIA, EAST JAVA, SURABAYA
Others
Have you ever used a passport under different name to enter Singapore? NO

Name different from current passport

DE Number: Z3888Q6415 VG

Health Declaration (Trip 1)

Have you visited any of the listed countries in Africa or Latin America in the NO
past 6 days prior to your arrival in Singapore?

Did you start to have any symptoms in the last 7 days: fever, rash, cough, runny NO
nose, sore throat, loss of sense of smell, or shortness of breath?

Do you currently have fever, cough, shortness of breath, headache, or vomiting NO

AND have visited Africa or the Middle East in the past 14 days prior to your
arrival in Singapore?

Are you fully vaccinated with WHO-EUL vaccines against COVID-19? VACCINATED.

Remarks PLEASE PRODUCE

COVID-19 VACCINATION
CERTIFICATE FOR
CHECKS BY TRANSPORT
OPERATORS AND/OR
AUTHORITIES.