Public Health Passenger Locator Form

Thank you for helping us protect your health

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Family Name: Jurisic First Name: Goran Gender: Male Date of birth: 1953-05-18
Nationality: Montenegro
Are you a resident of Mobile phone: +32491281386
Belgium?: No Passport or ID card number: P77RG1331

email address: jurisic.milivoje@gmail.com

Arrival date: 2022-05-12

Flight number: FR6042 Seat occupied during the flight: 30C

Location From To

Montenegro ( ME ) 2022-04-27 2022-05-12

Street: Avenue de l Hippodrome Number: 11 Box: 4 Country: Belgium State/Province: Ixelles

Zip/postal code: 1040 City: Brussels

Do you hold any of the following certificates?:

[V] Vaccination certificate

[V] Recovery certificate

Connecting flight (departing from Brussels): No

I hereby declare that above-mentioned information has been filled in correctly.: [v] You can
modify the PLF up to one day before your arrival in Belgium. Click here to modify your PLF.