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
SR2211100615631

Name Flight Number

KETAN RACHAMALLA SACHIDANAND QR572

Nationality Passport Number

INDIA L3773364

Date of Arrival Country of Departure ( Origin )

12/11/2022 UNITED STATES

Are you fully vaccinated? Location of Final Vaccination dose

Yes United States

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

27/05/2021 -

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

BANGALORE AIRPORT 1-11-29, GOLNAKA ALWAL,
SECUNDERABAD - 500010

Final Destination State/Union Territories Final Destination District/City

TELANGANA HYDERABAD

Final Destination Pincode Mobile Number

500010 +919848073575

Email ID
KETAN.RS08@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.