SGArrivalCard_290620240753

Thank you for using the Singapore Arrival Card!
This Singapore 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 Singapore Arrival Card is not a
visa. The use of the Singapore 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, and/or if there is any change in your health status and/or travel history.
You are required by law to submit a Cash (CBNI) Declaration if you are entering or leaving Singapore carrying
Physical Currency or Bearer Negotiable Instruments worth more than S$20,000 (or its equivalent in 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: 29/06/2024 07:53 AM (Singapore Time)

Number of travellers: 5
Lead Traveller NONIK CHUDAIFAH AINI QORIROH
Disembarkati Full Name (In Passport) Passport Number

on/
Embarkation
(DE) Number
X0782F6319 NONIK CHUDAIFAH AINI E3961279
QORIROH
Traveller 2 ADENAN

on/
Embarkation
(DE) Number
X0782F6414 ADENAN E6778195
Traveller 3 SUSMIATI

on/
Embarkation
(DE) Number
X0782F6511 SUSMIATI E4713303
Traveller 4 KUTRIYAH

on/
Embarkation
(DE) Number
X0782F6613 KUTRIYAH E6778196
Traveller 5 AGUS RAMADHAN

on/
Embarkation
(DE) Number
X0782F6716 AGUS RAMADHAN E7142793
Disembarkation/Embarkation (DE) Number: X0782F6319 NG
Personal Information
Full Name (In Passport)
NONIK CHUDAIFAH AINI QORIROH
Sex Date of Birth

FEMALE 04/10/1973
Place of Residence
INDONESIA, EAST JAVA, SURABAYA
Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
E3961279 22/09/2033
Mobile Number Email Address
+62 81241513669 KAMILAHTAG@GMAIL.COM
Trip Information
Date of Arrival
29/06/2024
Purpose of Travel
Religion
Mode of Travel
AIR
Mode of Transport Flight Number
COMMERCIAL FLIGHT QATAR AIRWAYS (QR) QR942
Type of Accommodation in Singapore Accommodation (Others)
OTHERS TRANSIT
Last City / Port of Embarkation Before Singapore
QATAR, AD DAWHAH, DOHA
Next City / Port of Disembarkation After Singapore
Date of Departure
29/06/2024
Others
Have you ever used a passport under different name to enter Singapore? NO
Electronic Health Declaration (Lead Traveller)
Do you currently have fever, cough, shortness of breath, headache or vomiting? NO
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?
Remarks NIL
ADENAN
Sex Date of Birth

MALE 22/06/1961
Place of Residence

E6778195 22/02/2034
Trip Information
Date of Arrival
29/06/2024
Purpose of Travel
Religion
Mode of Travel
AIR
OTHERS TRANSIT
Date of Departure
29/06/2024
Others
Electronic Health Declaration (Traveller 2)
Remarks NIL
SUSMIATI
Sex Date of Birth

FEMALE 07/07/1986
Place of Residence

E4713303 05/09/2033
Trip Information
Date of Arrival
29/06/2024
Purpose of Travel
Religion
Mode of Travel
AIR
OTHERS TRANSIT
Date of Departure
29/06/2024
Others
Remarks NIL
KUTRIYAH
Sex Date of Birth

FEMALE 01/01/1967
Place of Residence

E6778196 22/02/2034
Trip Information
Date of Arrival
29/06/2024
Purpose of Travel
Religion
Mode of Travel
AIR
OTHERS TRANSIT
Date of Departure
29/06/2024
Others
Remarks NIL
AGUS RAMADHAN
Sex Date of Birth

MALE 17/08/1979
Place of Residence
INDONESIA, CENTRAL JAVA, SEMARANG

E7142793 28/02/2034
Trip Information
Date of Arrival
29/06/2024
Purpose of Travel
Religion
Mode of Travel
AIR
OTHERS TRANSIT
Date of Departure
29/06/2024
Others
Remarks NIL

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Transaction Date: 29/06/2024 07:53 AM (Singapore Time)

Lead Traveller NONIK CHUDAIFAH AINI QORIROH

Disembarkati Full Name (In Passport) Passport Number

Disembarkati Full Name (In Passport) Passport Number

Disembarkati Full Name (In Passport) Passport Number

Disembarkati Full Name (In Passport) Passport Number

Traveller 5 AGUS RAMADHAN

Disembarkati Full Name (In Passport) Passport Number

Sex Date of Birth

Country/Place of Birth Nationality/Citizenship

Electronic Health Declaration (Lead Traveller)

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

Sex Date of Birth

Country/Place of Birth Nationality/Citizenship

Electronic Health Declaration (Traveller 2)

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

Sex Date of Birth

Country/Place of Birth Nationality/Citizenship

Electronic Health Declaration (Traveller 3)

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

Sex Date of Birth

Country/Place of Birth Nationality/Citizenship

Electronic Health Declaration (Traveller 4)

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

Sex Date of Birth

Country/Place of Birth Nationality/Citizenship

Electronic Health Declaration (Traveller 5)

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

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