Annex - A ® GOVERNMENT OF PAKISTAN owes (ee Rule 9 0) (@) (nue PERSONAL DECLARATION OF ORIGIN AND HEALTH eePreFLts ji NNAIRE FOR TRA Demographic Information 45,47 Name re Apr amet Contact number in Pakistan Passport Number aionaty 26? rigntn. Aun Ages U7 Sex: Male xr Female ‘Address in Pakistan ot ator TravelHistory: eles ‘Name of countries you have Visited in last 14 days Jer oe cura 7 Have you being in Contact with ves (lt Nol lu Visited Africa or South America inthe last 5 days Yes | up No jut ZL EIT Health status: efor Do you have any of the following, eet la thiol Fever] ae yell Nol lu? cough / a yes 14 No le Difficulty in breathing / Leal AL Yes 1 Noll Twill follow all public health measures adopted at the departure and arrival airport for COVID.19 thereby declare that the details furnished above are true and correct to the best of my knowledge. In case any of the above information Is found to be false or in correct, | am aware that | may be held liable for offence under Pakistan Panal Code. 1860 and public health safety laws and all applicable law(s) of Pakistan . Date & Placed — faite Signature [Intl SOP Version 3.0] Page 5