Self Declaration form details for international arriving passengers

Applications are being accepted on behalf of the Ministry of Health and Family Welfare, Government of India

___ PASSENGER DETAILS ___

Registration Number Date of Birth

SR2201060185963 01/02/1989

Name Seat Number

MD MAHMUDUR RAHMAN "00"

Flight Number Nationality

6E1088 INDIA

PNR Number Passport Copy Uploaded

SQFDXA No

Passport Number Country of Origin

N6185729 UNITED ARAB EMIRATES

Date of Arrival Domestic Connecting Flight

08/01/2022 6E6469

Are you taking a connecting Domestic flight? Date of RT-PCR Test Taken
YES 05/01/2022

RT-PCR Negative Certificate Uploaded Date of Final Dose of Vaccination

Yes 31/08/2021

Vaccination Certificate Uploaded First Airport of Entry

No LUCKNOW AIRPORT

City of Origin Final Destination - House Number

KOLKATA DERPARA

First Airport of Entry State/Union Territories Final Destination Tehsil

UTTAR PRADESH SAKTIPUR

Final Destination Street/Village Final Destination District/City

SAKTIPUR MURSHIDABAD

Final Destination State/Union Territories Contact Number

WEST BENGAL +916294435280

Final Destination Pincode Email ID

742163 MAHMUDURRAHMAN0@GMAIL.COM

Alternate Contact Number Diabetes

+919153082062 No
 Fever Hypertension
No No

Cough Bronchial Asthma

No No

Respiratory Distress Cancer

No No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
UNITED ARAB EMIRATES 1

I/We have agreed to the following terms:

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 undertake to quarantine/self monitor/take the self paid RTPCR test on arrival as applicable to me as per the latest
MOHFW guidelines.