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

SR2203301297998 10/03/1981

Name Seat Number

SUMITH ZACHARIAH 16C

Flight Number Nationality

6E1772 INDIA

PNR Number Passport Copy Uploaded

MHU6FY No

Passport Number Country of Origin

V7098743 QATAR

Date of Arrival Domestic Connecting Flight

01/04/2022

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 30/04/2021

Vaccination Certificate Uploaded First Airport of Entry

Yes MUMBAI AIRPORT

City of Origin Final Destination - House Number

DOHA THE WESTIN MUMBA

First Airport of Entry State/Union Territories Final Destination Tehsil

MAHARASHTRA GOREGAON

Final Destination Street/Village Final Destination District/City

OBEROI GARDEN CITY MUMBAI

Final Destination State/Union Territories Contact Number

MAHARASHTRA +97466233110

Final Destination Pincode Email ID

400063 ZACHARIAH.SUMITH@GMAIL.COM

Alternate Contact Number Diabetes

+97455841778 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 Qatar

Are you being evacuated from Ukraine by the Ministry of How many passengers are travelling?
External Affairs?
NO 1

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.