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
SR2208301454777

Name Flight Number

KRITHEESH EYYANI NHAYYAKKAT KRISHNAN 6E1847

Nationality Passport Number

INDIA T9484755

Date of Arrival Country of Departure ( Origin )

31/08/2022 OMAN

Are you fully vaccinated? Location of Final Vaccination dose

Yes Oman

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

15/03/2022 -

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

COCHIN AIRPORT KRISHNAN ENR, EYYANI NHAYYAKKAT,
NEAR RAMANKULAM, NATTIKA,
THRISSUR, KERALA

Final Destination State/Union Territories Final Destination District/City

KERALA THRISSUR

Final Destination Pincode Mobile Number

680566 +919846594502

Email ID
KRITHIKKRISHNA@GMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
4

CO PASSENGER DETAILS

Passenger 2

Name Flight Number

SANDHYA KRITHEESH 6E1847
 Nationality Passport Number
INDIA P4113973

Date of Arrival Country of Departure ( Origin )

31/08/2022 OMAN

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

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes Oman

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

15/03/2022 -

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

COCHIN AIRPORT KRISHNAN ENR, EYYANI NHAYYAKKAT,
NEAR RAMANKULAM, NATTIKA,
THRISSUR, KERALA

Final Destination State/Union Territories Final Destination District/City

KERALA THRISSUR

Final Destination Pincode Mobile Number

680566 +919846594502

Email ID
KRITHIKKRISHNA@GMAIL.COM

Passenger 3

Name Flight Number

VAISHNAV EYYANI NHAYYAKKAT KRITHEESH 6E1847

Nationality Passport Number

INDIA S4685463

Date of Arrival Country of Departure ( Origin )

31/08/2022 OMAN

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

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes Oman

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

29/09/2021 -

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
COCHIN AIRPORT KRISHNAN ENR, EYYANI NHAYYAKKAT,
NEAR RAMANKULAM, NATTIKA,
THRISSUR, KERALA

Final Destination State/Union Territories Final Destination District/City

KERALA THRISSUR

Final Destination Pincode Mobile Number

680566 +919846594502

Email ID
KRITHIKKRISHNA@GMAIL.COM

Passenger 4

Name Flight Number

KARTHIK EYYANI NHAYYAKKAT KRITHEESH 6E1847

Nationality Passport Number

INDIA U0369339

Date of Arrival Country of Departure ( Origin )

31/08/2022 OMAN

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

No -

Are you fully vaccinated? Location of Final Vaccination dose

No -

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

- 29/08/2022

I hereby certify that I have tested negative for COVID-19 and will produce the negative COVID-19 RT-PCR report* (The
test conducted within 72 hrs prior to undertaking the journey) for verification by the competent authority on arrival at
Indian airport.

First Airport of Entry Final Destination Address

COCHIN AIRPORT KRISHNAN ENR, EYYANI NHAYYAKKAT,
NEAR RAMANKULAM, NATTIKA,
THRISSUR, KERALA

Final Destination State/Union Territories Final Destination District/City

KERALA THRISSUR

Final Destination Pincode Mobile Number

680566 +919846594502

Email ID
KRITHIKKRISHNA@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.