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
SR2211201257204

Name Flight Number

INTISAR REZA ABIR 6E1864

Nationality Passport Number

BANGLADESH EH0468339

Date of Arrival Country of Departure ( Origin )

21/11/2022 BANGLADESH

Are you fully vaccinated? Location of Final Vaccination dose

Yes Australia

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

18/09/2021 -

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

KOLKATA AIRPORT HOTEL MOUNT VIEW, HILL CART ROAD,
SHILIGURI

Final Destination State/Union Territories Final Destination District/City

SIKKIM WEST DISTRICT

Final Destination Pincode Mobile Number

737101 +917001442369

Email ID
BIJOY71@ROCKETMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
1

CO PASSENGER DETAILS

Passenger 2

Name Flight Number

RAFEKA HIDER 6E1864
 Nationality Passport Number
BANGLADESH A02417730

Date of Arrival Country of Departure ( Origin )

21/11/2022 BANGLADESH

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

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes Bangladesh

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

27/10/2021 -

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

KOLKATA AIRPORT HOTEL MOUNT VIEW, HILL CART ROAD,
SHILIGURI

Final Destination State/Union Territories Final Destination District/City

SIKKIM WEST DISTRICT

Final Destination Pincode Mobile Number

737101 +917001442369

Email ID
BIJOY71@ROCKETMAIL.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.