Thank you for using the SG Arrival Card!

This SG Arrival Card is only valid for one time use for travel on the
expected date of arrival indicated below. You may choose to download or print a copy of this acknowledgement
and retain it for the duration of your stay.Please note that the SG Arrival Card is not a visa. The use of the SG
Arrival Card e-Service is free of charge.

The unauthorised consumption, possession, import, export and/or trafficking of any controlled drug is an offence
under Singapore's Misuse of Drugs Act. Under the Act, drug trafficking is punishable by death.

Providing false health and travel declarations is an offence under Section 64(b) of Singapore's Infectious Diseases
Act. The penalty for providing false or misleading information is a fine of up to S$10,000 and/or imprisonment of
up to 6 months. For subsequent offence(s), the penalty is a fine up to S$20,000 and/or imprisonment of up to 12
months.You are reminded that it is your responsibility to update and resubmit your declarations prior to your
arrival in Singapore, and/or if there is any change in your health status and/or travel history.

You are required by law to give a report using Form NP 727/A/B/C if the total value of currency and/or bearer
negotiable instruments you are carrying exceeds SGD 20,000 (or equivalent in a foreign currency).

If you are bringing in any item, or carrying an item for someone else, but you do not know what it contains, you
must declare the item at the Red Channel.

You can refer to the ICA website at Entering and Departing Singapore(https://www.ica.gov.sg/enter-depart) for
more information on Singapore's entry requirements and the list of prohibited or controlled items.

Transaction Date: 01/07/2023 12:55 AM (Singapore Time)

Number of travellers: 3

Lead Traveller SURYA WIJAYA

DE Number Full Name (In Passport) Passport Number

Y6551C7315 SURYA WIJAYA C8272030

Traveller 2 THELIA SARPINI

DE Number Full Name (In Passport) Passport Number

Y6551C7410 THELIA SARPINI X1725570
Traveller 3 HERLINA WIDJAJA

DE Number Full Name (In Passport) Passport Number

Y6551C7512 HERLINA WIDJAJA C9911094
DE Number: Y6551C7315 NG

Personal Information
Full Name (In Passport)
SURYA WIJAYA

Sex Date of Birth

MALE 16/04/1976
Place of Residence
INDONESIA, RIAU ISLANDS, BATAM

Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
C8272030 01/04/2027
Mobile Number Email Address
+62 82285735555 KEJORA.KONSORSIUM@GMAIL.COM

Trip Information
Date of Arrival in Singapore
01/07/2023
Mode of Travel
LAND
Mode of Travel (Details) Vehicle Number
VAN JTP8745
Type of Accommodation in Singapore Accommodation (Others)
OTHERS DAY TRIP
Last City / Port of Embarkation Before Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Next City / Port of Disembarkation After Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Date of Departure From Singapore
01/07/2023

Others
Have you ever used a passport under different name to enter Singapore? NO

Name different from current passport

DE Number: Y6551C7315 NG

Electronic Health Declaration (Lead Traveller)

Do you currently have fever, cough, shortness of breath, headache or vomiting? NO

Have you visited any of the listed countries in Africa or Latin America in the NO
past 6 days prior to your arrival in Singapore?

Remarks NIL
DE Number: Y6551C7410 NG

Personal Information
Full Name (In Passport)
THELIA SARPINI

Sex Date of Birth

FEMALE 12/01/1996
Place of Residence
INDONESIA, RIAU ISLANDS, BATAM

Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
X1725570 04/07/2027
Mobile Number Email Address
+62 82285735555 KEJORA.KONSORSIUM@GMAIL.COM

Trip Information
Date of Arrival in Singapore
01/07/2023
Mode of Travel
LAND
Mode of Travel (Details) Vehicle Number
VAN JTP8745
Type of Accommodation in Singapore Accommodation (Others)
OTHERS DAY TRIP
Last City / Port of Embarkation Before Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Next City / Port of Disembarkation After Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Date of Departure From Singapore
01/07/2023

Others
Have you ever used a passport under different name to enter Singapore? NO

Name different from current passport

DE Number: Y6551C7410 NG

Electronic Health Declaration (Traveller 2)

Do you currently have fever, cough, shortness of breath, headache or vomiting? NO

Have you visited any of the listed countries in Africa or Latin America in the NO
past 6 days prior to your arrival in Singapore?

Remarks NIL
DE Number: Y6551C7512 NG

Personal Information
Full Name (In Passport)
HERLINA WIDJAJA

Sex Date of Birth

FEMALE 03/01/1973
Place of Residence
INDONESIA, RIAU ISLANDS, BATAM

Country/Place of Birth Nationality/Citizenship

INDONESIA INDONESIAN
Passport Number Date of Passport Expiry
C9911094 20/07/2027
Mobile Number Email Address
+62 82285735555 KEJORA.KONSORSIUM@GMAIL.COM

Trip Information
Date of Arrival in Singapore
01/07/2023
Mode of Travel
LAND
Mode of Travel (Details) Vehicle Number
VAN JTP8745
Type of Accommodation in Singapore Accommodation (Others)
OTHERS DAY TRIP
Last City / Port of Embarkation Before Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Next City / Port of Disembarkation After Singapore
MALAYSIA, JOHOR, JOHOR BAHRU
Date of Departure From Singapore
01/07/2023

Others
Have you ever used a passport under different name to enter Singapore? NO

Name different from current passport

DE Number: Y6551C7512 NG

Electronic Health Declaration (Traveller 3)

Do you currently have fever, cough, shortness of breath, headache or vomiting? NO

Have you visited any of the listed countries in Africa or Latin America in the NO
past 6 days prior to your arrival in Singapore?

Remarks NIL