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Air Suvidha Self Reporting Form To be

Mandatorily Filled By All International
Arriving Passengers to India
Applications are being accepted on behalf of
the Ministry of Health and Family Welfare,
Government of India

Full Name* Date of Birth*

Darshankumar dilipbhai patel 01/10/1993

Flight number / Tail number* Seat Number*

LH760 38C

PNR Number Nationality*

MMTBNC India

Upload your
Passport Number* XIMG-
Passport Copy 20210105-
M4422320 Upload file type WA0000.jpg
JPEG & PDF
The maximum
upload size is
1MB.
File name with
any special
characters and
space are not
permitted. Only
hyphen and
underscore
permitted.
 

Date of Arrival* Country of Origin*

07/01/2021 COVID-19 UPDATE
Czech Republic
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City of Origin* First Airport of Entry*

Ostrava Delhi Airport

First Airport of Entry Final Destination - House

State/Union Territories* Number*

New Delhi 2/214

Final Destination Final Destination Tehsil

Street/Village*
Borsad
Patel khadki/banejada

Final Destination State/Union Final Destination District/City*

Territories*
Anand
Gujarat

Final Destination Pincode* Contact Number*

388580 +91 7016407567

Alternate Contact Number Email ID*

+91 9601096810 darshanpatel799@gmail.com

Are you experiencing any of the Are you suffering from*

following symptoms?*
Diabetes Yes No
Fever Yes No Hypertension Yes No
Cough Yes No Bronchial Asthma
Respiratory Distress Cancer Yes No  
Yes No Yes No
Under Immunosuppresive
Therapy

Yes No
 COVID-19 UPDATE Post
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Yes No Air Suvidha 

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

Ostrava (70800)

How many passengers

- 1 +
are travelling?

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 would undergo mandatory quarantine for 14 days i.e. 7 days paid institutional
quarantine at my own cost, followed by 7 days isolation at home with self-
monitoring of health.

In case you develop symptoms such as fever and cough within 28 days of leaving
this airport, restrict your outdoor movement and contact MoHFW's 24 hours helpline
number 011-23978406. Call operator will tell you whom to contact further. In the
meanwhile, keep yourself isolated in your house/room.

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