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
SR2209070323200

Name Flight Number

ABDUL SAMATH SARABI AK23

Nationality Passport Number

INDIA N2018030

Date of Arrival Country of Departure ( Origin )

07/09/2022 MALAYSIA

Are you fully vaccinated? Location of Final Vaccination dose

Yes India

Date of Final Dose of Vaccination Date of RT-PCR Test Taken

24/07/2022 -

I hereby certify that I am vaccinated for COVID-19 and will produce the supporting document for verification by the
competent authority on arrival at Indian airport.

First Airport of Entry Final Destination Address

TRICHY AIRPORT 115/14A/1 SINGAMPADAIYACHE
STREET, THIRUCHENGODU, NAMAKKAL

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU NAMAKKAL

Final Destination Pincode Mobile Number

637211 +919597117907

Email ID
SHBANU21@GMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
3

CO PASSENGER DETAILS

Passenger 2

Name Flight Number

ABDUL SAMATH ABDUL KARIM AK23
 Nationality Passport Number
INDIA N2018098

Date of Arrival Country of Departure ( Origin )

07/09/2022 MALAYSIA

Is the passenger less than 5 years of age? Date of Birth

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes India

Date of Final Dose of Vaccination Date of RT-PCR Test Taken

24/07/2022 -

I hereby certify that I am vaccinated for COVID-19 and will produce the supporting document for verification by the
competent authority on arrival at Indian airport.

First Airport of Entry Final Destination Address

TRICHY AIRPORT 115/14A/1 SINGAMPADAIYACHE
STREET, THIRUCHENGODU, NAMAKKAL

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU NAMAKKAL

Final Destination Pincode Mobile Number

637211 +919597117907

Email ID
SHBANU21@GMAIL.COM

Passenger 3

Name Flight Number

SHEIKH MOHAMMED HALIMAH AK23

Nationality Passport Number

INDIA N2018032

Date of Arrival Country of Departure ( Origin )

07/09/2022 MALAYSIA

Is the passenger less than 5 years of age? Date of Birth

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes India

Date of Final Dose of Vaccination Date of RT-PCR Test Taken

18/07/2022 -

I hereby certify that I am vaccinated for COVID-19 and will produce the supporting document for verification by the
competent authority on arrival at Indian airport.
 First Airport of Entry Final Destination Address
TRICHY AIRPORT 115/14A/1 SINGAMPADAIYACHE
STREET, THIRUCHENGODU, NAMAKKAL

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU NAMAKKAL

Final Destination Pincode Mobile Number

637211 +919597117907

Email ID
SHBANU21@GMAIL.COM

I/We have agreed to the following terms:

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

I undertake to quarantine/self monitor/take the self paid Covid-19 test on arrival as applicable to me as per the latest
MOHFW guidelines.

I, the primary applicant/passenger, authorise to be contacted by the Ministry of Health and Family Welfare, Government
of India, for the purpose of identification and related checks of my co-passenger(s), if required. 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, the primary applicant, certify that the information filled is correct and true.