Passenger Health Undertaking

Dear SELVI NADAR

Greetings From Air India !

Your Form for Passenger Health Undertaking submitted successfully as per following details :

No of Mobile Date of Health Submitted

Email ID Name Address Pincode Flight No PNR Sector
Passenger No Travel Status By
219-B,
BALAJI
Self or/and on
BHAVAN,
BALBALAJIBA behalf of
NORTH CAR
LA@YAHOO. SELVI NADAR 3 628151 9870772788 671 J4SPL 19-08-2021 BOMIXM Yes group
STREET,
CO.IN travelling
UMARIKADU
together
THOOTHUKUDI
TAMILNADU

The passenger has given a declaration to the following effect :

i) I/We am/are not residing in any containment zone.

ii) I/We am/are not suffering from any fever/cough/any respiratory distress.
iii) I/We am/are not under quarantine.
Or

I/We am/are under quarantine, but having a negative RT-PCR test report, for which test was conducted within 96
hours prior to undertaking the journey from abroad.
iv) if I/We develop any of the above-mentioned symptoms i shall contact the concerned health authorities
immediately.
v) I/We am/are not COVID-19 positive or I/We were diagnosed with COIVD-19 and after having treatment
recovered (COVID-19 recovered persons fulfilling this condition will be allowed to travel upon showing COIVD-19
recovered /discharged certificate from any institution dealing with COVID-19 / recently issued COVID-19 negative
certificate from any testing centers approved by ICMR).
vi) I/We am/are eligible to travel as per the extant norms.
vii) I/We will make my mobile number / contact details available to the airlines whenever required by them.
viii) I/We understand that if I/We undertake the air journey without meeting the eligibility criteria, I/We will be
liable to penal action.
ix) I/We understand that it is mandatory to wear masks and maintain social distancing norms at all times during Air
Travel. The mask shall not be moved below the nose except under exceptional circumstances. x) I/We undertake to
adhere to the health protocol prescribed by the destination state / UT.