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

R PASSENGER DETAILS V

Registration Number
SR2208060292056

Name Flight Number

NAVASHKHAN SATHIK BATCHA 6E1792

Nationality Passport Number

INDIA P1664207

Date of Arrival Country of Departure ( Origin )

07/08/2022 UNITED ARAB EMIRATES

Are you fully vaccinated? Location of Final Vaccination dose

Yes United Arab Emirates

Date of Final Dose of Vaccination Vaccination Certificate Uploaded

05/08/2021 Yes

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

06/08/2022 Yes

First Airport of Entry Final Destination Address

CHENNAI AIRPORT NO.4/87 MUSLIM STREET

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU THANJAVUR

Final Destination Pincode Mobile Number

614802 +919994603970

Email ID
NAVASHKHAN.786@OUTLOOK.COM

How many passengers are travelling with you in the same flight and to the same final destination?
1

I/We have agreed to the following terms:

I agree to the guidelines issued by Ministry of Health & Family Welfare.

I, the primary applicant, verify that the information filled is correct and agree to be contacted for the co - passenger
contact tracing. 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 undertake to quarantine/self monitor/take the self paid RTPCR test on arrival as applicable to me as per the latest
MOHFW guidelines.