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    This document contains a health declaration and screening summary for a traveler named Haughton Andre with a passport number of M00170587. It provides key details such as his nationality, date of birth, countries visited in the last 21 days, destination and duration of stay in Nigeria, emergency contact information, and confirms he has been fully vaccinated and has not experienced any COVID symptoms or sick contact in the last 21 days.

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    This document contains a health declaration and screening summary for a traveler named Haughton Andre with a passport number of M00170587. It provides key details such as his nationality, date of birth, countries visited in the last 21 days, destination and duration of stay in Nigeria, emergency contact information, and confirms he has been fully vaccinated and has not experienced any COVID symptoms or sick contact in the last 21 days.

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    © All Rights Reserved
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    2 views1 page

    Result

    Uploaded by

    Andre Haughton
    This document contains a health declaration and screening summary for a traveler named Haughton Andre with a passport number of M00170587. It provides key details such as his nationality, date of birth, countries visited in the last 21 days, destination and duration of stay in Nigeria, emergency contact information, and confirms he has been fully vaccinated and has not experienced any COVID symptoms or sick contact in the last 21 days.

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    © All Rights Reserved
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    of 1

    YOUR HEALTH DECLARATION & SCREENING SUMMARY

    Fully Vaccinated

    PERMIT TO
    TRAVEL

    Phone Number Passport Number


    09154906711 M00170587

    Gender Nationality
    Male South Africa

    Date of Birth Country of Residence


    28/04/1988 South Africa

    Travel
    Details

    Flight Number Departure Airport Arrival Airport


    ET901 O.R. Tambo International Airport Lagos
    Seat Number

    COUNTRIES VISITED
    IN THE LAST 21 DAYS

    South Africa,

    DESTINATION IN NIGERIA
    FOR THE LAST 21 DAYS

    Address 1 City, State Duration of stay


    33 Creek Road Apapa Lekki Lagos, Lagos 2 month(s)

    EMERGENCY CONTACT OR NEXT OF KIN


    IN NIGERIA

    Name Phone Number Address


    Yewande Ogunrindw 08099736888 33 Creek Road Apapa Lekki

    HEALTH DETAILS

    SYMPTOMS SICK PERSON CONTACT MEDICATION


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

    LAB

    Passenger Name Arrival Date Vaccination Status


    Signature
    Haughton Andre 28/04/2022 Fully Vaccinated

    Fully Vaccinated (NO PAYMENT)

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