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 V

Registration Number Date of Birth

SR2207120677447 30/06/1990

Name Gender
SIJO MOHANAN MALE

Flight Number Seat Number

G9448 00

PNR Number Nationality

60186525 INDIA

Passport Number Country of Origin

V6076909 BAHRAIN

Date of Arrival Domestic Connecting Flight

17/07/2022

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

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

No 17/10/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes TRIVANDRUM AIRPORT

City of Origin Final Destination - House Number

MANAMA , BAHRAIN 559

First Airport of Entry State/Union Territories Final Destination Tehsil

KERALA NOORANAD

Final Destination Street/Village Final Destination District/City

ATTUVA IRANIKUDY ALAPPUZHA

Final Destination State/Union Territories Contact Number

KERALA +919037788074

Final Destination Pincode Email ID

690558 SIJOMOHANAN1990@GMAIL.COM

Alternate Contact Number Diabetes

+918281015751 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 Bahrain

Are you fully vaccinated?

YES

How many passengers are travelling with you in the same flight and to the same final destination?
2

CO PASSENGER DETAILS

Passenger 2

Name Date of Birth

JOHANN PALAMTHALACKAL SIJO 12/07/2018

Flight Number Gender

G9448 MALE

PNR Number Seat Number

60186525 00

Passport Number Nationality

S6634758 INDIA

Date of Arrival Country of Origin

17/07/2022 BAHRAIN

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

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

No -

Vaccination Certificate Uploaded Date of Final Dose of Vaccination

No -
 City of Origin First Airport of Entry
MANAMA , BAHRAIN TRIVANDRUM AIRPORT

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

KERALA 559

Final Destination Street/Village Final Destination Tehsil

ATTUVA IRANIKUDY NOORANAD

Final Destination State/Union Territories Final Destination District/City

KERALA ALAPPUZHA

Final Destination Pincode Contact Number

690558 +919037788074

Alternate Contact Number Email ID

+918281015751 SIJOMOHANAN1990@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? Location of Final Vaccination dose
NONE

Are you fully vaccinated?

I/We have agreed to the following terms:

I agree to the guidelines issued by Ministry of Health & Family Welfare.

I, the primary applicant, verify that the information filled is correct and agree to be contacted for the co - passenger
contact tracing. In case of any default, the primary applicant will be liable for punishable offences under the provisions of
the relevant Indian Laws. 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.