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

PASSENGER DETAILS

Registration Number
@
SR2104130290688

Name Date of Birth

ANTONY PETER 25/06/1990

Flight Number Seat Number

FZ8515 DNK

PNR Number Nationality

R0VPR2 INDIA

Passport Number Passport Copy Uploaded

S2854120 Yes

Date of Arrival Country of Origin

15/04/2021 SOUTH SUDAN

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

JUBA CHENNAI AIRPORT

First Airport of Entry State/Union Territories Final Destination - House Number

TAMIL NADU HILL TOP

Final Destination Street/Village Final Destination Tehsil

ST THOMAS MOUNT CHENNAI

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU CHENNAI

Final Destination Pincode Contact Number

600016 +9194459704142

Alternate Contact Number Email ID

CHENNAI@MANGALAMTRAVEL.COM

Fever Diabetes
No No
Cough Hypertension
No No

Respiratory Distress Bronchial Asthma

No No

Cancer
No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
NONE 3

CO PASSENGER DETAILS

Passenger 2 @

Name Date of Birth

NAVEEN KUMAR 28/02/1991

Flight Number Seat Number

FZ8515 DNK

PNR Number Nationality

R0VPR2 INDIA

Passport Number Passport Copy Uploaded

U7873532 Yes

Date of Arrival Country of Origin

15/04/2021 SOUTH SUDAN

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

JUBA CHENNAI AIRPORT

First Airport of Entry State/Union Territories Final Destination - House Number

TAMIL NADU HILL TOP

Final Destination Street/Village Final Destination Tehsil

ST THOMAS MOUNT CHENNAI
Final Destination State/Union Territories Final Destination District/City
TAMIL NADU CHENNAI

Final Destination Pincode Contact Number

600016 +919445970142

Alternate Contact Number Email ID

CHENNAI@MANGALAMTRAVEL.COM

Fever Diabetes
No No

Cough Hypertension
No No

Respiratory Distress Bronchial Asthma

No No

Cancer
No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days?

NONE

Passenger 3 @

Name Date of Birth

PRASANTH 09/05/1991

Flight Number Seat Number

FZ8515 DNK

PNR Number Nationality

R0VPR2 INDIA

Passport Number Passport Copy Uploaded

S2853732 Yes

Date of Arrival Country of Origin

15/04/2021 SOUTH SUDAN

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes
 City of Origin First Airport of Entry
JUBA CHENNAI AIRPORT

First Airport of Entry State/Union Territories Final Destination - House Number

TAMIL NADU HILL TOP

Final Destination Street/Village Final Destination Tehsil

ST THOMAS MOUNT CHENNAI

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU CHENNAI

Final Destination Pincode Contact Number

600016 +919445970142

Alternate Contact Number Email ID

CHENNAI@MANGALAMTRAVEL.COM

Fever Diabetes
No No

Cough Hypertension
No No

Respiratory Distress Bronchial Asthma

No No

Cancer
No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days?

NONE

I/We have agreed to the following terms:

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

The above information is correct and in case of any wrong information and non-cooperation, I will be liable for action
under the law. 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.