Visitor travel & symptoms declaration form (last updated 4 August 2020)

Location of proposed visit ☐ JA  AT ☐ ATA ☐ Other

Name Manoj

Mobile no. 0559545263

Email address Sajesh.V@alshola.com

Gender  Male ☐ Female Age: 45

Nationality India

1) Have you travelled outside ☐ Yes

the UAE since June 30 2020
 No
If you answer YES, then please answer questions (a,b,c).

a) Countries visited NA
(including airport stopovers)

b) Date of arrival to UAE NA

c) Were you tested for ☐ Yes

COVID-19 on arrival to UAE?
☐ No

Date of your last COVID-19 Date result received: Result:

test:
17/03/2022 ☐ Positive  Negative
17/03/2022

SYMPTOMS DECLARATION:

 I declare that I have not experienced any symptoms like fever, cough, difficulty breathing,
sore throat, headache or loss of smell & taste in the past 2 weeks.
☐ I declare that I have had one or more of the above symptoms during the past 2 weeks. Provide
details here ________________________________________________________

Name & signature: Date: 24/03/2022

Documents to be submitted along with this form:

 Emirates ID (or passport information page if unavailable)
 Evidence of negative COVID-19 test taken within past 96 hours
 Evidence of any travel since June 30 2020 (eg passport stamp, ticket, boarding pass)
 ALHOSN

Covid-19 ‫ﺗﻘﺮﻳﺮ ﻓﺤﺺ‬

Test Report 19 - ‫ﻛﻮﻓﻴﺪ‬

Name ‫اﻻﺳﻢ‬

MANOJKUMAR GOPALAN ‫ﻣﺎﻧﻮﺟﻜﻮﻣﺎر ﺟﻮﺑﺎﻻن ﺟﻮﺑﺎﻻن‬

GOPALAN
Passport Number ‫رﻗﻢ ﺟﻮاز اﻟﺴﻔﺮ‬

M8955812 M8955812
Emirates ID ‫اﻟﻬﻮﻳﺔ اﻻﻣﺎراﺗﻴﺔ‬

784197697360515 784197697360515
Date of Birth ‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬

25 May 1976 1976 ‫ ﻣﺎﻳﻮ‬25

Test Result ‫ﻧﺘﺎﺋﺞ اﻟﻔﺤﺺ‬

PCR Negative PCR ‫ﺳﻠﺒﻲ‬

Test Date ‫ﺗﺎرﻳﺦ اﻟﻔﺤﺺ‬

14:07 - 17 Mar 2022 2022‫ ﻣﺎرس‬17 - 14:07

Result Date ‫ﻧﺘﻴﺠﺔ اﻟﻔﺤﺺ‬

23:29 - 17 Mar 2022 2022‫ ﻣﺎرس‬17 - 23:29

Test Lab ‫ﻣﺨﺘﺒﺮ اﻟﻔﺤﺺ‬

MUSAFFAH M12 MUSAFFAH M12

Copyright ©2022. All rights reserved. Ministry of Health & Prevention. United Arab Emirates
 Covid-19 ‫ﺑﻄﺎﻗﺔ اﻟﺘﻄﻌﻴﻢ‬
Vaccination Card 19 - ‫ﻛﻮﻓﻴﺪ‬

Full Name ‫اﻻﺳﻢ اﻟﻜﺎﻣﻞ‬

MANOJKUMAR GOPALAN ‫ﻣﺎﻧﻮﺟﻜﻮﻣﺎر ﺟﻮﺑﺎﻻن ﺟﻮﺑﺎﻻن‬

GOPALAN
Passport Number ‫رﻗﻢ ﺟﻮاز اﻟﺴﻔﺮ‬

M8955812 M8955812
Emirates ID ‫اﻟﻬﻮﻳﺔ اﻻﻣﺎراﺗﻴﺔ‬

784197697360515 784197697360515
Date of Birth ‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬

25 May 1976 1976 ‫ ﻣﺎﻳﻮ‬25

Emirate ‫اﻹﻣﺎرة‬

Abu Dhabi ‫أﺑﻮ ﻇﺒﻲ‬

First dose 2021.02.03 ‫اﻟﺠﺮﻋﺔ اﻷوﻟﻰ‬

Sinopharm (202011147)

Second dose 2021.03.04 ‫اﻟﺠﺮﻋﺔ اﻟﺜﺎﻧﻴﺔ‬

Sinopharm (202012371)

Third dose 2021.12.31 ‫اﻟﺠﺮﻋﺔ اﻟﺜﺎﻟﺜﺔ‬

Sinopharm (202108B2159)

Copyright ©2021. All rights reserved. Ministry of Health & Prevention. United Arab Emirates