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
@
SR2106110094960

Name Date of Birth

DEEPESH SINGH THAKUR 12/04/1978

Flight Number Seat Number

LH760 NA

PNR Number Nationality

VGNNT2 INDIA

Passport Number Passport Copy Uploaded

K7940780 Yes

Date of Arrival Country of Origin

13/06/2021 GERMANY

Are you taking a connecting Domestic flight? Domestic Connecting Flight

YES 6E5051

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

DELHI DELHI AIRPORT

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

NEW DELHI A465

Final Destination Street/Village Final Destination Tehsil

MAHALAXMI NAGAR INDORE

Final Destination State/Union Territories Final Destination District/City

MADHYA PRADESH INDORE

Final Destination Pincode Contact Number

452010 +911727985354

Alternate Contact Number Email ID

+918088138061 T.DEEPESH31@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? How many passengers are travelling?
NA 3

CO PASSENGER DETAILS

Passenger 2 @

Name Date of Birth

TANVI RATHOR 05/01/1985

Flight Number Seat Number

LH760 NA

PNR Number Nationality

JDJX7L INDIA

Passport Number Passport Copy Uploaded

U0988057 Yes

Date of Arrival Country of Origin

13/06/2021 GERMANY

Are you taking a connecting Domestic flight? Domestic Connecting Flight

YES 6E5051

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

DELHI DELHI AIRPORT

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

NEW DELHI A465

Final Destination Street/Village Final Destination Tehsil

MAHALAXMI NAGAR INDORE
Final Destination State/Union Territories Final Destination District/City
MADHYA PRADESH INDORE

Final Destination Pincode Contact Number

452010 +918088138061

Alternate Contact Number Email ID

+918088138061 T.DEEPESH31@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?

NA

Passenger 3 @

Name Date of Birth

KUBER SINGH THAKUR 13/08/2014

Flight Number Seat Number

LH760 NA

PNR Number Nationality

JDJX7L INDIA

Passport Number Passport Copy Uploaded

U0890990 Yes

Date of Arrival Country of Origin

13/06/2021 GERMANY

Are you taking a connecting Domestic flight? Domestic Connecting Flight

YES 6E505

RT-PCR Negative Certificate Uploaded

Yes
 City of Origin First Airport of Entry
GERMANY DELHI AIRPORT

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

NEW DELHI A465

Final Destination Street/Village Final Destination Tehsil

MAHALAXMINAGAR INDORE

Final Destination State/Union Territories Final Destination District/City

DELHI INDORE

Final Destination Pincode Contact Number

452010 +918088138061

Alternate Contact Number Email ID

+918088138061 T.DEEPESH31@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?

NA

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.