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asians — ingest tiwaiiuil Ose
Kind of conveyance Aircraft Fgh No, Ship Name of hip
bug Grp oc Ose vai Oso0wk weiiowse
‘ee psi) Tain No. Crus. License pate No
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From To Seat No
suit ROW conte Monn WM OMAUM ON
Date Month Year Passport No.
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Name nl Natinaiy
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Age Yeas Gender Male Female
aim Cth = Ciingsis Ganty wit Oo dvace
Occupation Civil servant Business. Employee Housekeeper Other (specif)
Shintialssmn tno
Adress in Taian a sii
nqanuonderlsemnn 9 vino oojmalumesdlmniiousniiascine nes
Please list the name of the countries where you stayed within two weeks before aval
aa sees ‘
Samtosmne ¥ idoviniiomsmdil Womotunsounuluaoatiantivinandalzemalno
Please mark ¥ if you have any ofthe following symptoms within two weeks before arrival
Caomneiaitoutw Corio Orrefor OW Oiliows tune 0 Auawdiame
Dian Vomiting Abdominal pain Fever Headache, Sore That Rash
Cfiim = Oordometedunn Qoiombindasta Wituuaia = Odu a Gerp.
Jaundice Cough and Shortness of Breath Enlarged lymph glands or tender amps Other (specify)
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Shofar sage
wwostogodaynna sun uqutseinnosey dseann
Port Health Officer
ani
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