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
SR2211120689893

Name Flight Number

JOHN GUALBERT JOSE AI934

Nationality Passport Number

INDIA T6490960

Date of Arrival Country of Departure ( Origin )

12/11/2022 UNITED ARAB EMIRATES

Are you fully vaccinated? Location of Final Vaccination dose

Yes United Arab Emirates

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

24/10/2021 -

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

COCHIN AIRPORT 10C ASTRA OLIVE KALISTA EDACHIRA
KAKKANAD THENGODU PO.

Final Destination State/Union Territories Final Destination District/City

KERALA ERNAKULAM

Final Destination Pincode Mobile Number

682030 +919446896874

Email ID
JOHNGJOSE@GMAIL.COM

How many passengers are travelling with you in the same flight and to the same final destination?
2

CO PASSENGER DETAILS

Passenger 2

Name Flight Number

JIGI JOHN AI934
 Nationality Passport Number
INDIA R0542487

Date of Arrival Country of Departure ( Origin )

12/11/2022 UNITED ARAB EMIRATES

Is the passenger less than 5 years of age? Date of Birth

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes United Arab Emirates

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

24/10/2021 -

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

COCHIN AIRPORT 10C ASTRA OLIVE KALISTA EDACHIRA
KAKKANAD THENGODU PO.

Final Destination State/Union Territories Final Destination District/City

KERALA ERNAKULAM

Final Destination Pincode Mobile Number

682030 +919446896874

Email ID
JOHNGJOSE@GMAIL.COM

Passenger 3

Name Flight Number

ROSY JOSEPH AI934

Nationality Passport Number

INDIA U1276805

Date of Arrival Country of Departure ( Origin )

12/11/2022 UNITED ARAB EMIRATES

Is the passenger less than 5 years of age? Date of Birth

No -

Are you fully vaccinated? Location of Final Vaccination dose

Yes India

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

18/08/2021 -

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
COCHIN AIRPORT 10C ASTRA OLIVE KALISTA EDACHIRA
KAKKANAD THENGODU PO.

Final Destination State/Union Territories Final Destination District/City

KERALA ERNAKULAM

Final Destination Pincode Mobile Number

682030 +919446896874

Email ID
JOHNGJOSE@GMAIL.COM

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.