6/19/2020 ServicePlus- Covid-19: Apply here to travel to Karnataka from other Indian states by road/rail/flight

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Traveller Details/ಪ ಾ ಕರ ವರಗಳ /या ी का िववरण

Name of the traveller/ಪ ಾ ಕರ Vijay Vishnu Kumbhar

ೆಸರು/या ी का नाम :

Mobile Number of the traveller/ 9763679777

ಪ ಾ ಕರ ೂ ೈ ಸಂ ೆ /या ी का
मोबाइल नंबर :

Gender/ ಂಗ/िलंग : Male/ಪ ರುಷ

Age/ವಯಸು /उ : 35

Which category of travellers do you Business Traveler

belong to?/ ೕವ ಾವ ಪ ಾ ಕರ
ವಗ ೆ ೇ ೕ ?/आप िकस वग के या ी
ह? :

Present Address Details/ವತ ಾನ ಾಸ ವರಗಳ /वतमान पते का िववरण

Address 1/ ಾಸ 1/पता पं 1: At.Post.Tambave.Tal-Karad,

Address 2/ ಾಸ 2/पता पं 2: Dist-Satara, Maharashtra

Address 3/ ಾಸ 3/पता पं 3: 415114

Country/ ೇಶ/दे श : India

State/ ಾಜ /रा : MAHARASHTRA

District/ ೆ/िजला : SATARA

Taluk/ ಾಲೂಕು/तालुक : KARAD

Postal Code/ ೕಸ ೋ /िपनकोड : 415114

Address to which you are travelling to/ತಲುಪ ೇ ಾದ ಾಸ/आप जहाँ जा रहे ह उसका पूरा पता िल खये
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6/19/2020 ServicePlus- Covid-19: Apply here to travel to Karnataka from other Indian states by road/rail/flight

Type/ ಾದ / कार : Urban

Address 1/ ಾಸ 1/पता पं 1: Airmen Training School

Address 2/ ಾಸ 2/पता पं 2: Sambara

Address 3/ ಾಸ 3/पता पं 3: Belgavi

State/ ಾಜ /रा : KARNATAKA

District/ ೆ/िजला - Urban : BELAGAVI

Urban Local Body/ನಗರ ಸ ೕಯ ೇಹ/ Belagavi

शहरी थानीय िनकाय :

Postal Code/ ೕಸ ೊ ೕ /िपनकोड : 591124

Are you travelling with your family?/ No/ಇಲ/नहीं

ಮ ಕುಟುಂಬ ೊಂ ೆ ೕವ
ಪ ಾ ಸು ೕ ಾ?/ ा आप अपने
प रवार के साथ या ा कर रहे ह? :

Entry Details/ಪ ೇಶ ವರಗಳ / वेश िववरण

Mode of entry to Karnataka/ Road

ಕ ಾ ಟಕದ ಪ ೇಶ ಾನ/कनाटक म
वेश का तरीका :

Entry Check post / ಪ ೇಶ ೆ ೕ / NH-4 Koganoli Taluk, Nippani

िवि चेकपो :

Date of Arrival at Karnataka/ 22/06/2020

ಕ ಾ ಟಕದ ಆಗಮನದ ಾಂಕ/कनाटक म
आगमन की ितिथ :

Business Traveler Details - Details of the person you intend to meet in Karnataka/ ಾ ಾರ ಪ ಾ ಕರ
ವರಗಳ - ೕವ ಕ ಾ ಟಕದ ೇ ಾಗಲು ಬಯಸುವ ವ ಯ ವರಗಳ /िबजनेस टै वलर िववरण - उस
का िववरण िजसे आप कनाटक म िमलना चाहते ह

Name/ ೆಸರು : Gurvindar Singh Flora

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6/19/2020 ServicePlus- Covid-19: Apply here to travel to Karnataka from other Indian states by road/rail/flight

Mobile Number/ ೂ ೈಲ ಂ ೆ / 7760108959

मोबाइलनंबर :

Address/ ಾಸ/पतापं : Airmen Training School,Sambara ,Belgavi

Date of return/ ಂ ರು ದ ಾಂಕ/ 23/06/2020

लौटनेकीतारीख :

Declaration/ ೂೕಷ ೆ/घोषणा

I hereby declare that details submitted above are true and correct to the best of my knowledge and belief and I undertake
that if anything is found untrue I shall be liable for punishment/penalty as per law.

I hereby declare tofollow quarantine and testing norms prescribed by Government of Karnataka and I am willing to bear
charges, as applicable

I Agree : Yes

Annexure List

1) Covid-19 test result Report

2) Address proof of person in Address Proof

Karnataka he intends to meet

Additional Details

Apply to the Office Revenue Department (STATE)

Draft Reference No : Draft_RD813S/2020/301183

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