YOUR HEALTH DECLARATION & SCREENING SUMMARY

PERMIT TO
TRAVEL

Phone Number Passport Number

08060666638 516398234

Gender Nationality
Male United States

Date of Birth Country of Residence

17/10/1968 United States

Travel
Details

Flight Number Departure Airport Arrival Airport

DL54 Hartsfield-Jackson Atlanta International Lagos
Seat Number

COUNTRIES VISITED
IN THE LAST 21 DAYS

United States,

DESTINATION IN NIGERIA
FOR THE LAST 21 DAYS

Address 1 City, State Duration of stay

54 Olaifa St lagos, Lagos 45 day(s)

EMERGENCY CONTACT OR NEXT OF KIN

IN NIGERIA

Name Phone Number Address

Dayo Origunwa 08060666626 2124 Manhattan Parkway

HEALTH DETAILS

SYMPTOMS SICK PERSON CONTACT MEDICATION

IN THE LAST 21 DAYS IN THE LAST 21 DAYS IN THE LAST 24 HOURS

LAB
ME CURE (OSHODI)

Passenger Name Arrival Date Vaccination Status

Signature
Origunwa Obafemi 18/05/2022 Unvaccinated

PAID