freer Sry cat ferro gat oes sare trae BE aT TW ea ah aET OE TR eT H A E ‘aft aargeg watt enfbeary w wry sefterrttemé weg ere | seers PA eT Me eRReete ME | BY FLIGHT servers 4, 176605 40 fed. FlightWVehicle No. 17669508295: ‘Seat No. ae a MANISHA ae fe SHE ~~ | First Name is! Lastname bebsalinl 3% (Malo) afta fare artic alee Femmes Ory Jes halal ere (Nepal 3 (Other) ant faa halal rear (Passport)! > | cue ee in |198804-10 a ara, 11254308 (re) | | pao on (Citizenship) = | Distiet e | [rete er Ber | amen, wat. visa 1.0 | Permanent Province District | Municipalty'vilage| Ward No. Town Vilage adress | Tarr Tet weer ‘faieor SLT wat. is et ten weet ert Province District | Municipality/Village ‘Ward No. TownVillage Hotel Aacress cm Wile Staying in [A er aroaneey [eran 6 Nepal amt lea PT dee | vette) ‘9603461647 Email ‘manishastha59@@gmail.com babe Personal Contact No. + | Contact paekie strait sme = ada. Nepal [882 | frat Full Name Relation Contact Husband/WterGuardian No. ara Por (30 Fahy | Travel History (Past 30 Days) ae 7 carat ara aed ‘a e From To Mode of Travel Flight/Vehicle No, Date 1 ft ene ort erent feet erent . ‘Travelling Country af | Country Name (Germany a Saving city Qa eh ndhatae [ER eer e9 (Rotuming) is ker eR (Not Returning) | BW Rs omag te) ized cet oe Reve aT Future Return Pian to |y.2 Country Name Where You Will | NA Nepal Stay, If Not Returningeareea ftewor (Health Information) No ca ere eee wt EO (ves) [Br (NOS Have You Tested Postve For COVID-19? a ae a fr a eee eT RON (Yes) S| ny Heath Issues For The Past One Month? oe ‘aie ee wt a ere ere 509) [es moyo Any Laboratory Tests Conducted For COVID-19 e : rare wien sg, weer FAR OTHER 3)°3° | virich Laboratory Test Has Been Conducted For You? Pons} oo eee ae FRAT Fan | Positve | Negative ae pozzoeoa uaa |, | Poste | Meas ay [SRemr earl ae D “ Laboratory Name Where Test Has Been Done Central Dtagoneetio re Perera ag (v) Fre TTIG Mark (V) If You Ate Suttering From Folowing Symptoms (38° C00. Foret a aa (ves) “| ever (More Than 38° C/100.4"F) ome ae ¥ (Yes) 03 Ooooh O°) feo ae tee (ves) 3 | piticuityn Breathing [eros aormegae 1 (Yes) sn |e O°) feo arena (Yes) fx] aa [re O°) fey farang (Yes) 0 omg [so aera ge (Yes) S00 aeane O° fer err ea 1 (Yes) era Nid OP | one eset ger 1 (Yes) out |e Oe) | one rary (Yes) oe ee Ofer oy tt eu Far ere ara ae Ten ST STG MT wes 442 | Have You Come in Contact With Patents Showing Symptoms Of Breathing Ditcutis in The Past |") J oye 14 Daye? gl | AREER rer ee yc aa Brea we) ‘42 |Have You Recently Atened To Any Sick People Or Been In Contac With Any Person Dying Of |" No} Unknown Causes? sag [Freee BE meer aT IT TR #069) [es moe “** | Have You Recently Been In Contact With A Dead Body Or Attended A Funeral? o Brae a drat Rear stn der ney TT (Yes) “+ | Are You Under Medication For Any Chronic Medical Condition Disease? o fe 8) | Rafat reer gr at am ‘82 | Please Specity Any Chronic Condition You Have ‘Walwor (Self-Declaration) + salar at tac fw wget oR erent TE Allthe above details are correct and | am ready to face false actions.ee ee White in Quarantine, | will follow the health guidelines issued by the government. + mopar ert we t8 aA wa re eat ro zw aT Te TATE TT TTT et ES TET 1 | will follow all the rules of discipline to save myself, my family and my country from this disease so that this disease does not spread in my family and society. ID: 532603 Fite MANISHA SHRESTHA 22-06-09 20:30:06 03461647 = wa aga Pte aeTr HPT sre Ferre Departure W Point of Exit Ray Ree eT ane POAT TETAS | Each passenger must compete this form and submit itto the Health Desk at Arial or Point of Enty of Trbhuvan Intemational Aiport + Pear aga ore eer Vege eT a wT | Get inthe habit of washing your hands regularly with soap and water using sanitizer, _—_« WEA vt | Please Use a Mask + aero nef arewEAA A, GT BIE | When coughing, cover your nose and mouth with a mask or elbow. + rate gft Tam Ta | Please maintain socal distance _ag ws, sree wt Beier zs ent FrekaTA wt is our responsibility to protect not only ourselves but also others. ‘agaist anf wararg_I1fThanks for the support I! ‘aedhret anf wer Contact for assistance eat er ar rarer ree 2a, ToT ‘wrr .01-4255796 (we: 1000-1700) Fer: ewarsedod @gmal.com aT we Ber A.tees (Toll Free), Facebook: www facebook comedednepal