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

R PASSENGER DETAILS V

Registration Number Date of Birth

SR2203150611835 30/01/1976

Name Seat Number

RAGHVENDRA SHRIVASTAVA 20D

Flight Number Nationality

AI216 INDIA

PNR Number Passport Copy Uploaded

HKF4R Yes

Passport Number Country of Origin

U9788955 NEPAL

Date of Arrival Domestic Connecting Flight

15/03/2022

Are you taking a connecting Domestic flight? Date of RT-PCR Test Taken
NO 14/03/2022

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

Yes 14/08/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes DELHI AIRPORT

City of Origin Final Destination - House Number

KATHMANDU B-601, MANOKAMNA

First Airport of Entry State/Union Territories Final Destination Tehsil

NEW DELHI DWARKA

Final Destination Street/Village Final Destination District/City

PLOT NO. 16, SECTOR 18A, DWARKA SOUTH WEST

Final Destination State/Union Territories Contact Number

DELHI +919910406152

Final Destination Pincode Email ID

110078 SHRIRAGHVENDRA@YAHOO.COM

Alternate Contact Number Diabetes

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? Location of Final Vaccination dose
NONE India

Are you being evacuated from Ukraine by the Ministry of How many passengers are travelling?
External Affairs?
NO 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.