GENERAL DECLARATION

(Outward/Inward)
Operator: VIETNAM AIRLINES (SKY TEAM MEMBER)
Marks of Nationality and Registration: VNA613 Flight No: VN 5631 Date: 22Jun2021
Departure from: HO CHI MINH CITY, VIET NAM Arrival at: JAKARTA SOEKARNO-HATTA APT, INDONESIA

FLIGHT ROUTING & TOTAL NUMBER OF CREW

PLACE RANK NAME STAFF PASSPORT PASSPORT DOB NAT GENDER NUMBER OF
NUMBER NO EXPIRY PASSENGERS ON
THIS STAGE
Operating _________________
SGN CAPT DO HOANG NAM PHUC 7 4383 C3463333 21Jun2027 21Apr1984 VIET NAM M
CGK Departure place
SGN FO NGUYEN DUC NINH 4 4614 B7450023 30Nov2022 31Aug1988 VIET NAM M SGN
CGK Embarking
SGN Y TRAN THI NGOC DANG 11 5165 C2902195 23Mar2027 30Nov1994 F
CGK
Through on
SGN Y VO THI NGOC DUNG 80 5045 C2605184 22Dec2026 09Dec1993 F same flight
CGK

Arrival place
CGK
Disembarking

Through on
same flight

DECLARATION OF HEALTH FOR OFFICIAL USE ONLY

Name and seat number or function of persons on board with illnesses other than airsickness or the
effects of accidents, who may be suffering from communicable disease ( a fever - temperature
38°C/100° F or greater - associated with one or more of the following signs or symptoms, e.g
appearing obviously unwell; persistent coughing; impaired breathing; persistent diarrhoea; persistent
vomiting; skin rash; bruising or bleeding without previous injury; or confusion of recent onset, increases
the likelihood that the person is suffering a cummunicable disease) as well as such cases of illness
disembarked during a previous stop.

Details of each disinsecting of sanitary treatment (place, date, time, method) during the flight. If no
disinsecting has been carried out during the flight give details of most recent disinsecting.

______________________________________
Signed if required, with time and date
Crew member concerned
I declare that all statements and particulars contained in this General Declaration and in any supplementary forms requires to be presented
with this General Declaration are complete, exact and true to the best of my knowledge and that all through passengers will continue / have
continued on the flight.

Signature: _____________________________________________
Authorised Agent of Pilot-in-command