feo air eo oR aircon rere we Sere age ag rE TT es Tee eT Ss BTA a A a eT ae af eT aT wo forces ate BT | ser Fae CSTEV TEA Te) 2ORR-016-26, TE | BY FLIGHT ID: 555264 Seraaa rignivenice |91254 Bee Seat No. No a co 8 erat Name| AMESHWOR & Lastname WALA ene IE (Male) Aer (Female) arateera » ale Pi tonoe te Gremeny | M4 epee 94 (Ome or Fate care a | ‘ean rear (Pass000 | ogg issue Date uw 2073-01-01 ae hand Date of ith Cee (SH 7 jervinmwo) (eens | ost reat Sart sen fet | aman at asa cr Province Distret | Municipaityvitage| Ward No Towrvitage 8) facies sar arr aaa wer farce aT ast rig Bear ert Province Distnct |uncipattyvitago| Ward No | Towvilago | Hott 1c |aceross io Sts | a areal |wroastanm | new plaza = a fsramm | a¢e [ote 902256506 an emaime@gmei'com ad Porsonal Contact No 7 28 | contac ae Datos in | ey apse yas By Nepal mae : HusbanarwierGuardan| *U! Name Relation oor ara) Fara ed 30 FE Travel History (Past 30 Days) x a rr sre a Bie From 10 Mod of Travl Rowse Dato 5 No. 1 | Katmandu [Doha Plane aoa ‘(2002.07.26 sates Beer erat a eae 2 | Traveling Country |*® [country Name [AUS B Sauna fovcney e FRAN FET (Retmingyge PRAIA WA Wot RetumiNgI Sars 3 ad aha aR, Y Peamedaey faced wed ae deel aFuture Return Plan to Nepal bad ‘Country Name Where You Will | NA Siay, f Not Returning sare faaquT (Health Information) Please Specify Any Chronic Condition You Have tag | ET HRS 40 are Serta Be ERT Byes\O FF Noe Have You Tastod Positive For COVID-19? Feet Web AGA WaT A RAY TH LE “3 [any Heattn issues For The Past One Month? Soja | Woe alfns.ag a af cara wale a oa « ta Beesic | Foe Any Laboratory Tests Conducted For GOVID-19 errhp ae a, ee FL “3132 | wich Laboratory Test Has Boon Conducted For You? POR@ | OTHERG aero ae Tae ea 4a | ate zoaza6.20 |4aa |O' | Posie | Negawe g vay aero Rept arent x STAT Laboratory Name Where Test Has Been Done are Fr aren cer a ( Ferg ay Mark (1) You Ate Suffering From Following Symptoms vey [P28 Cit00 4° F ral as araPH B (Yes) | BA (No) Fever (More Than 38° C/100.4"F) ole eg {SO B (Yes) | BA (No) Cough ols wg [eH (ves) | BT INO) Dificuly n Breathing ol|e yy [RH (es) | BA (No) Tinos o |e wee fen [POTT B (Yes) | BA (No) Diartnea o|s ye ara ga B (Ves) | 34 (No) Yorniting ols caw RR (ves) | BT INo) Blooding ole weg [A B (Yes) | BA (No) Rashes ole va | OD Boren) | Sano) Headache ole x go FA B (Vos) | 7 (No) Loss of Small o|s Reet i FT RATIOS SPR SARL HTT OMIT ATA STS MET B (ves) | B7(No) ‘4 Have You Como n Contact With Paton Showing Symptoms OF Boating Difculos In Tho Past] ©) |" O 14 Days? uae ere Fare a ore eee py ge a BT HET eves) | B4 (he) 442 | Have You Recently Attended To Any Sick People Or Been In Contact With Any Person Dying Of Unknown Causes? o| ag RE eae eer ecg (ves) | BTN) Have You Recently Been In Contact With A Dead Body Or Altonded A Funeral? o |e ag [SRR RE eT ewe ote Sera oe B (ves) | Brno) Are You Under Medication For Any Chronic Medical Condition’ Disease? ole we war ee eet aT HAT THT AT ‘FUIWUM (Self Declaration + Saas a8 fara foe o gel oe rere in TURE)ae ee eee ee eee en eae eee + Radar era Ear ITN ATOTATE aT ALT TTA EG While in Quarantine, | wil follow the heath guidelines issued by the government. ar ra are. 0¢ Hea wa Pra rm BAT a bah a are oT See BRT SGT wa Pa wy UeTTig | | will follow all the rules of discipline to save myself, my family and my country from this disease so that this disease does nc spread in my family and society. Pew UU A eae Frwy RAMESHWOR WALLA ID: 566264 ata ——boor. 06-20 17.1836 fer. 1802256596 > ei aa gHSTT aORT HAC PR STA OATS Departure a Pont of Ext HT Ea Red Sew SAT wu GIT AT 1] Each passongor must completo ths form and submit to the Heath Dosk at Ava or Poin of Entry of Tribhuvan Intemational port > Rati Sgt arid ew Gea ware ard wee | Ca nthe habit of washing your hands egulay wih Soep and water using saniizer + HTepT MM | Plaase Use a Mask + shac gareg 1c sren/g RAE ATH, FB STA | When coughing, cover your nose and mouth vith 8 mask or elbow. «safes GUST TH | Please maintain social istanco ‘Sayy ra BH, sive WPT Getera Ted wre erwiaT wT is our responsiblity to protect not only ourselves but also others ‘REGIE ATA, WET | Thanks forthe support cit fa ars Contact for assistance fateh aun dn Pron rere 2g, wrsHTTE ‘Wh 7.01-4265796 (HE: 1000-1700) AR: ewarsedcd@gmall com UAT LT 7.422 (Tol Free), Facebook: vi facebook comiedcdnepal