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
SR2211181081895

Name Flight Number

AYOUB LAACHACHI GF132

Nationality Passport Number

MOROCCO AO6521697

Date of Arrival Country of Departure ( Origin )

20/11/2022 MOROCCO

Are you fully vaccinated? Location of Final Vaccination dose

Yes Morocco

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

22/09/2022 -

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

DELHI AIRPORT GAUTAM BUDDHA UNIVERSITY, OPP,
YAMUNA EXPY, GREATER NOIDA,
UTTAR PRADESH PIN CODE- 201312,
INDIA

Final Destination State/Union Territories Final Destination District/City

UTTAR PRADESH GAUTAM BUDDHA NAGAR

Final Destination Pincode Mobile Number

201312 +212663836150

Email ID
AYOUB.LAAC@GMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
0

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.