Ministry of Health and Family Welfare

Government of India

SELF REPORTING FORM TO BE FILLED BY ALL INTERNATIONAL PASSENGERS

(TO BE PRESENTED AT THE HEALTH & IMMIGRATION COUNTER)

All persons coming to India are required to fill-up this Proforma in duplicate & submitting a copy each to Health
and Immigration Counter.

Personal Information Contact Address in India for All Travelers:

1 Name of 1 House Number

the
passenger 2 Street/ Village
2 Seat No. 3. Flight
No. 3 Tehsil
4 Passport
No. 4 District/ City
5 Nationality
5 State
6 Age
6 Pin
7 Date of
Arrival 7 Residence Number
8 Port of
origin of 8 Mobile Number *
Journey (mandatory field)
9 Port of 9 E mail ID
final
destination
(PART-A)

a. Details of the cities / countries visited in last 14 days? ____________________________

b. Are you suffering from any of the following symptoms

 Fever Yes No
 Cough Yes No
 Respiratory distress Yes No
 Are you suffering from (Please Indicate) – (Hypertension, Diabetes , Bronchial Asthma, Cancer, Under
Immunosuppresive therapy, Post Transplant patients) - _____________________________________
 The above information is correct and in case of any wrong information and non-cooperation, I will be liable for
action under the law.

Signature of the passenger

In case you develop symptoms such as fever and cough within 28 days of leaving this airport, restrict your outdoor movement and
contact MoHFW’s24 hours helpline number 011-23978046. Call operator will tell you whom to contact further. In the meanwhile,
keep yourself isolated in your house/room.
 Air India

Indemnity - Quarantine Cost & Deportation Charges

I undertake this journey at my own risk of contracting any disease including COVID-19 and
Air India will not be liable for any costs incurred or damages suffered upon, either direct or
indirect, as a result of or incidental to such illness and I release Air India from any liability of
any kind arising there from. I shall follow Quarantine and / or any other instructions as
prescribed by health authorities, at prescribed location, at my own cost on arrival at
destination (14 days as prescribed currently)

I also undertake to bear the entire cost of deportation including penalties if any levied on Air
India, the cost of return air fare in case I am refused admittance on arrival at the destination
country.

Signature

Passenger Name:

Passport No:

Contact No:

Flight No: Date:

It is mandatory to submit the duly signed undertaking at the time of check-in .

 Undertaking cum Indemnity Bond
(to be filled in by all the passengers)

To,

High Commission of India,

Wellington, New Zealand

Subject: Consent Form for evacuation from...............................(City, NZ)

1. I......................................................................(name, city) holding valid

Indian passport.................. (passport number), confirm my willingness to return
to India.

2. I confirm my readiness to follow all instructions given by the officials of

Government of India/Embassy of India/Aircraft crew/medical personnel on
arrival.

3. I am also willing to undergo a 7 days mandatory quarantine on my arrival

in India at my own expense as per the protocols framed by the Government of
India and 7 days of home quarantine.

4. I fully understand that while travelling in the special repatriation flight, I

may be inadvertently exposed to any infection, including COVID-19 virus, and
having fully understood the risk to my person, I voluntarily give consent to travel
to India in the special repatriation flight. I undertake and agree that neither I nor
my heirs nor my executors nor administrators will hold responsible Union of
India, any official of Union of India or staff of airline or any of my fellow
passengers for any injury to me (including death) or loss of property due to any
accidental exposure.

(Signature with date)

Name:.........................................................
Passport Number:...............................
Mobile:.....................................
Email:................................................
 Undertaking (for those not belonging to Delhi)

To,

High Commission of India,

Wellington, New Zealand

Subject: Consent Form for evacuation from...............................(City, NZ)

1. I agree to be quarantined in one of the facilities in Delhi, Delhi NCR or

Haryana; or Bhiwadi or Chandigarh.

2. I will pay for the quarantine during the mandatory period of 7 days, after
which I will subject myself to home quarantine.

3. I will not insist on returning to my state of domicile, (if quarantined in Delhi)

before completing the mandatory period of quarantine.

4. After the quarantine period is over, I will return to my state of domicile,

either by making my own arrangements or through the arrangements facilitated
by the Resident Commissioner/ Nodal Officer of the concerned State.

(Signature with date)

Name:.........................................................
Passport Number:...............................
Mobile:.....................................
Email:................................................