Self Declaration form details for international arriving passengers

Applications are being accepted on behalf of the Ministry of Health and Family Welfare, Government of India

___ PASSENGER DETAILS V

Registration Number
SR2210140794503

Name Flight Number

VIJIL VIJAYAN EK564

Nationality Passport Number

INDIA N4942706

Date of Arrival Country of Departure ( Origin )

15/10/2022 CYPRUS

Are you fully vaccinated? Location of Final Vaccination dose

Yes India

Date of Final Dose of Vaccination Date of RT-PCR Test Taken

27/12/2021 -

I hereby certify that I am vaccinated for COVID-19 and will produce the supporting document for verification by the
competent authority on arrival at Indian airport.

First Airport of Entry Final Destination Address

BANGALORE AIRPORT CALICUT, VADUVANCHAL PO, 673581

Final Destination State/Union Territories Final Destination District/City

KERALA WAYANAD

Final Destination Pincode Mobile Number

673581 +919745463142

Email ID
VIJILVIJAYAN01@GMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
0

I/We have agreed to the following terms:

I agree to the guidelines issued by Ministry of Health & Family Welfare.

I undertake to quarantine/self monitor/take the self paid Covid-19 test on arrival as applicable to me as per the latest
MOHFW guidelines.

I, the primary applicant/passenger, authorise to be contacted by the Ministry of Health and Family Welfare, Government
of India, for the purpose of identification and related checks of my co-passenger(s), if required. In case of any default, the
primary applicant will be liable for punishable offences under the provisions of the relevant Indian Laws. I also agree to
the terms & conditions.

I, the primary applicant, certify that the information filled is correct and true.