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: 05/05/2022 05:34 PM (Singapore Time)

Trip 1 Date of Arrival to Singapore 06/05/2022

DE No Full Name (In Passport) Passport Number

Z3113E3219 KENN HENRIADI TEJASURYA C9124942
DE No: Z3113E3219 NG

Personal Information
Full Name (In Passport)
KENN HENRIADI TEJASURYA

Sex Date of Birth

MALE 25/03/2000
Place of Residence
INDONESIA, WEST JAVA, BANDUNG

Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
C9124942 25/05/2022
Mobile Number Email Address
+62 85974912526 KENNHENRIADI@GMAIL.COM

Trip Information and Declaration

Trip Information
Date of Arrival to Singapore Date of Departure From Singapore
06/05/2022 12/05/2022
Mode of Travel
AIR
Mode of Travel (Details) Flight Number
COMMERCIAL GARUDA INDONESIA (GA) GA836
Type of Accommodation in Singapore Name of Hotel
HOTEL 30 BENCOOLEN
Last City / Port of Embarkation Before Singapore
INDONESIA, WEST JAVA, BANDUNG
Next City / Port of Disembarkation After Singapore
INDONESIA, WEST JAVA, BANDUNG
Others
Have you ever used a passport under different name to enter Singapore? NO

Name different from current passport

DE No: Z3113E3219 NG

Health Declaration (Trip 1)

Have you visited Africa or Panama or South America (except Chile) in the past 6 NO
days prior to your arrival in Singapore?

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

Have you visited Africa or the Middle East in the past 14 days prior to your NO
arrival in Singapore, AND, any of the following symptoms currently: fever, cough,
shortness of breath, headache, vomiting?

Have you taken a COVID-19 vaccination? VACCINATED.

Remarks PLEASE PRODUCE

COVID-19 PRE-
DEPARTURE TEST (PDT)
RESULT [FOR NON-FULLY
VACCINATED
TRAVELLERS ABOVE 12
YEARS OLD] FOR CHECKS
BY TRANSPORT
OPERATORS AND/OR
AUTHORITIES.