Passenger Locator Form

STATUS: NON-RED LIST

VACCINE STATUS: DECLARED FULL/EXEMPT

The code contains personal

information. By sharing the code,
you will be sharing your passenger
locator form data.

Summary
Name Kamil Jaroslawski
Passport number EK1126653
Which company are you travelling with? Ryanair UK Limited
What is the flight number, train number or ship FR4136
name that you will arrive on?
Reference UKVI_5ZAA018608434
Status NON-RED LIST
What are your travel plans? Stay in the UK
Are you required to book a COVID-19 test Yes
package for when you arrive in the UK?
Your test package booking reference CTLME2486963
Arrival location Bristol Airport (BRS)
Date of arrival 12 October 2021 21:35 British Summer Time
(BST)
Date of submission 11 October 2021 10:48 British Summer Time
(BST)

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 UK Visas & Immigration

Personal information

Email address kamo_baczek@wp.pl

Travel information

Do you have an address for where you will stay Yes

during your first 10 days in the UK?

You provided the following address as your Yes

residential address. Do you plan on staying at this
address?
FLAT 8
4 BERKELEY STREET
CHELTENHAM
GL522SX

What address will you stay at for your first 10 days FLAT 8
in the UK? 4 BERKELEY STREET
CHELTENHAM
GL522SX

When will you arrive there? 12 October 2021

What are your travel plans? Stay in the UK

Where will you arrive in the UK? Bristol Airport (BRS)

What country are you travelling from? Poland

Which company are you travelling with? Ryanair UK Limited

What is the flight number, train number or ship FR4136

name that you will arrive on?

What is your seat number? 27F

Which countries have you been in, or will you be in, Poland
for the 10 days before coming to the UK?

Have you visited, or will you visit, any islands in this Yes
country during the 10 days before you arrive in the
UK?

What is the name of the island you have, or will Zakynthos

visit?

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 UK Visas & Immigration
Have you visited, or will you visit, the mainland of No
this country?

Arrival date 1 October 2021

Departure date 8 October 2021

Are you required to book a COVID-19 test package Yes

for when you arrive in the UK?

Your test package booking reference CTLME2486963

Your dates of travel

When do you plan to arrive in the UK? 12 October 2021 21:35 PM

Personal information

Given name(s) Kamil

Family name / Surname Jaroslawski

What is your sex? Male

Is your home address in the UK? Yes

Home address FLAT 8

4 BERKELEY STREET
CHELTENHAM
GL522SX
(manually entered)

How can we contact you when you are in the UK? I can be contacted by phone call and text message
(SMS)

Date of birth 13 March 1990

Your primary phone number +44 7521973895

Do you meet the COVID-19 vaccination eligibility Yes

criteria for reduced isolation and testing
requirements?

Do you have a QR code that you can scan to verify No

your vaccination status?

Have you provided proof of your vaccination No

status?

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 UK Visas & Immigration

Have you been fully vaccinated from COVID-19? Yes

Which country did you receive your COVID-19 England (United Kingdom of Great Britain and
vaccination(s) in? Northern Ireland)

Passport and travel document details

Passport number or travel document reference EK1126653

number

Country of Issue Poland (POL)

Expiry date 9 May 2026

People you are travelling with

Are you travelling to the UK with anyone under 18 No

years old that you are including on this form?

Declaration
I declare that:

I will arrive in the UK within the next 48 hours

I understand I have to provide proof of negative coronavirus (COVID-19) test result if I am travelling from a
red list country or island, unless I am exempt
I understand that I must bring proof of my COVID-19 vaccination status if I meet the eligibility criteria. My
proof of vaccination status (if declared) contains my full name, date of birth, vaccine brand and
manufacturer, the dates for all my vaccination doses and the country of vaccination and/or certificate
issuer
I have provided my seat number, if relevant
The information I have entered in this form is correct
I understand it could be a criminal offence to provide false details and I may be prosecuted

I confirm that I understand and agree with the above declarations.

Kamil Jaroslawski Page 4 of 4