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

T PASSENGER DETAILS

Registration Number
@
SR2110200525758

Name Date of Birth

MOHAMMED GOUSE SHAIKH HUSSAIN 12/07/1969

Flight Number Seat Number

AHE4RF 0

PNR Number Nationality

INDIA

Passport Number Passport Copy Uploaded

N1269530 Yes

Date of Arrival Country of Origin

21/10/2021 UNITED ARAB EMIRATES

Are you taking a connecting Domestic flight? Domestic Connecting Flight

YES 6E7965

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

DUBAI COCHIN AIRPORT

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

KERALA HUBLI

Final Destination Street/Village Final Destination Tehsil

HUBLI

Final Destination State/Union Territories Final Destination District/City

KARNATAKA DANDELI

Final Destination Pincode Contact Number

581325 +919886392311

Alternate Contact Number Email ID

+918296174391 MOHAMMED.GOUSE@ALROSTAMANIGROUP.AE

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? How many passengers are travelling?
DUBAI 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.