Passenger Locator Form

STATUS: NON-RED LIST

VACCINE STATUS: DECLARED FULL/EXEMPT

The code contains personal

information. By sharing the code,
you will be sharing your passenger
locator form data.

Summary
Name YUIKA NAGASE
Passport number TT1848938
Which company are you travelling with? EUROSTAR
What is the flight number, train number or ship 9055
name that you will arrive on?
Reference UKVI_5ZAA021727133
Status NON-RED LIST
What are your travel plans? Stay in the UK
Are you required to book a COVID-19 test Yes
package for when you arrive in the UK?
Your test package booking reference BOOTS4304072
Arrival location London St Pancras (Eurostar)
Date of arrival 30 October 2021 20:30 British Summer Time
(BST)
Date of submission 30 October 2021 03:13 British Summer Time
(BST)

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 UK Visas & Immigration

Personal information

Email address yn0823_5067@icloud.com

Travel information

Do you have an address for where you will stay Yes

during your first 10 days in the UK?

You provided the following address as your Yes

residential address. Do you plan on staying at this
address?
65-69 Holmes Rd,Kentish Town
London
NW5 3AN

What address will you stay at for your first 10 days 65-69 Holmes Rd,Kentish Town
in the UK? London
NW5 3AN

When will you arrive there? 30 October 2021

When will you leave there? 27 August 2022

What are your travel plans? Stay in the UK

Where will you arrive in the UK? London St Pancras (Eurostar)

What country are you travelling from? France

Which company are you travelling with? EUROSTAR

What is the flight number, train number or ship 9055

name that you will arrive on?

Which countries have you been in, or will you be in, France
for the 10 days before coming to the UK?

Have you visited, or will you visit, any islands in this No

country during the 10 days before you arrive in the
UK?

Arrival date 27 October 2021

Departure date 30 October 2021

Which countries have you been in, or will you be in, Japan

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 UK Visas & Immigration
for the 10 days before coming to the UK?

Have you visited, or will you visit, any islands in this No

country during the 10 days before you arrive in the
UK?

Arrival date 23 October 2021

Departure date 23 October 2021

Are you required to book a COVID-19 test package Yes

for when you arrive in the UK?

Your test package booking reference BOOTS4304072

Your dates of travel

When do you plan to arrive in the UK? 30 October 2021 20:30 PM

Personal information

Given name(s) YUIKA

Family name / Surname NAGASE

What is your sex? Female

Is your home address in the UK? Yes

Home address 65-69 Holmes Rd,Kentish Town

London
NW5 3AN
(manually entered)

How can we contact you when you are in the UK? I can only be contacted by text message (SMS)

Date of birth 23 August 2001

Your primary phone number +44 07742995229

Do you meet the COVID-19 vaccination eligibility Yes

criteria for reduced isolation and testing
requirements?

Have you been fully vaccinated from COVID-19? Yes

Which country did you receive your COVID-19 Japan

vaccination(s) in?

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 UK Visas & Immigration

Passport and travel document details

Passport number or travel document reference TT1848938

number

Country of Issue Japan (JPN)

Expiry date 27 August 2031

People you are travelling with

Are you travelling to the UK with anyone under 18 No

years old that you are including on this form?

Declaration
I declare that:

I understand I have to provide proof of negative coronavirus (COVID-19) test result if I am travelling from a
red list country or island, or do not qualify as fully vaccinated, unless I am exempt
I understand that I must bring proof of my COVID-19 vaccination status if I meet the eligibility criteria. My
proof of vaccination status (if declared) contains my full name, date of birth, vaccine brand and
manufacturer, the dates for all my vaccination doses and the country of vaccination and/or certificate
issuer
The information I have entered in this form is correct
I understand it could be a criminal offence to provide false details and I may be prosecuted

I confirm that I understand and agree with the above declarations.

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