Passenger Locator Form

STATUS: AMBER
VACCINE STATUS: NO/NOT DECLARED

The code contains personal

information. By sharing the code,
you will be sharing your passenger
locator form data.

Summary
Name Zignon Kouassi Joseph David
Passport number 20AA22458
Which company are you travelling with? EUROSTAR
What is the flight number, train number or ship 9145
name that you will arrive on?
Reference UKVI_5ZAA010871586
Status AMB
What are your travel plans? Stay in the UK
Are you required to self-isolate when you arrive in I need to self-isolate when I arrive in the UK,
the UK? unless I was fully vaccinated in the UK or under a
vaccine programme approved by the UK or I have
only been in green list countries or islands
Are you required to book a COVID-19 test Yes
package for when you arrive in the UK?
Covid test booking reference COVID2136271
Test to release provider 247 Home Testing
Arrival location London St Pancras (Eurostar)
Date of arrival 22 August 2021 17:03 British Summer Time (BST)
Date of submission 22 August 2021 07:14 British Summer Time (BST)

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Personal information

Email address dj.zignonk@gmail.com

Travel information

Do you have an address for where you will stay Yes

during your first 10 days in the UK?

You provided the following address as your Yes

residential address. Do you plan on staying at this
address?
80 NORBURY AVENUE
THORNTON HEATH
Cr7 8af

What address will you stay at for your first 10 days 80 NORBURY AVENUE
in the UK? THORNTON HEATH
Cr7 8af

When will you arrive there? 22 August 2021

Are you required to self-isolate when you arrive in I need to self-isolate when I arrive in the UK, unless I
the UK? was fully vaccinated in the UK or under a vaccine
programme approved by the UK or I have only been
in green list countries or islands

What are your travel plans? Stay in the UK

Where will you arrive in the UK? London St Pancras (Eurostar)

What country are you travelling from? France

Which company are you travelling with? EUROSTAR

What is the flight number, train number or ship 9145

name that you will arrive on?

What is your seat number? Coach 1 seat 31

Which countries have you been in, or will you be in, France
for the 10 days before coming to the UK?

Have you visited, or will you visit, any islands in this No

country during the 10 days before you arrive in the
UK?

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 UK Visas & Immigration
Arrival date 18 August 2021

Departure date 22 August 2021

Your dates of travel

When do you plan to arrive in the UK? 22 August 2021 17:03 PM

Personal information

Given name(s) Zignon

Family name / Surname Kouassi Joseph David

What is your sex? Male

Is your home address in the UK? Yes

Home address 80 NORBURY AVENUE

THORNTON HEATH
Cr7 8af
(address verified)

How can we contact you when you are in the UK? I can be contacted by phone call and text message
(SMS)

Date of birth 21 November 2001

Your primary phone number +44 07426463263

Your secondary phone number (optional) +44 7491299112

Do you meet the COVID-19 vaccination eligibility No/Prefer not to say

criteria for reduced isolation and testing
requirements?

Passport and travel document details

Passport number or travel document reference 20AA22458

number

Country of Issue Ivory Coast (CIV)

Expiry date 2 January 2030

People you are travelling with

Are you travelling to the UK with anyone under 18 No

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 UK Visas & Immigration
years old that you are including on this form?

Declaration
I declare that:

I will arrive in the UK within the next 48 hours

I understand I have to provide proof of a negative COVID-19 test prior to departure to the UK (unless I am
exempt)
I understand that I must bring proof of my COVID-19 vaccination status if I meet the eligibility criteria
I have provided my seat number, if relevant
The information I have entered in this form is correct
I understand it could be a criminal offence to provide false details and I may be prosecuted

If any of your information changes once you have submitted your form, such as travel details, seat number, or
contact information, you must complete a new form.

I confirm that I understand and agree with the above declarations.

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