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

SR2111240764126 08/01/1995

Name Seat Number

DIPAK BHIMJI KARA 34F

Flight Number Nationality

G9481 KENYA

PNR Number Passport Copy Uploaded

69195054 Yes

Passport Number Country of Origin

AK0078483 KENYA

Date of Arrival Domestic Connecting Flight

25/11/2021

Are you taking a connecting Domestic flight? Date of RT-PCR Test Taken
NO 23/11/2021

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

Yes 08/06/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes AHMEDABAD AIRPORT

City of Origin Final Destination - House Number

NAIROBI NA

First Airport of Entry State/Union Territories Final Destination Tehsil

GUJARAT AHMEDABAD

Final Destination Street/Village Final Destination District/City

AHMEDABAD AHMEDABAD

Final Destination State/Union Territories Contact Number

GUJARAT +919265465929

Final Destination Pincode Email ID

382424 DIPESHBHIMA@GMAIL.COM

Alternate Contact Number Diabetes

+919265465929 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?
NAIROBI 2

CO PASSENGER DETAILS

Passenger 2

Name Date of Birth

KAMLESH RAMESHBHAI VAGANI 18/01/1992

Flight Number Seat Number

G9481 34E

PNR Number Nationality

69195581 INDIA

Passport Number Passport Copy Uploaded

U0422612 Yes

Date of Arrival Country of Origin

25/11/2021 KENYA

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded Date of RT-PCR Test Taken

Yes 23/11/2021

Vaccination Certificate Uploaded Date of Final Dose of Vaccination

Yes 08/09/2021

City of Origin First Airport of Entry

NAIROBI AHMEDABAD AIRPORT

First Airport of Entry State/Union Territories Final Destination - House Number

GUJARAT NA
 Final Destination Street/Village Final Destination Tehsil
AHMEDABAD AHMEDABAD

Final Destination State/Union Territories Final Destination District/City

GUJARAT AHMEDABAD

Final Destination Pincode Contact Number

382424 +919265465929

Alternate Contact Number Email ID

+919265465929 KAMLESHVAGHANI@GMAIL.COM

Fever Diabetes
No No

Cough Hypertension
No No

Respiratory Distress Bronchial Asthma

No No

Cancer
No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

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

NAIROBI

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.