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

Registration Number
@
SR2110020028595

Name Date of Birth

THAIYUB 24/01/1988

Flight Number Seat Number

6E1776 6E

PNR Number Nationality

VR34SK INDIA

Passport Number Passport Copy Uploaded

N9681555 No

Date of Arrival Country of Origin

02/10/2021 QATAR

Are you taking a connecting Domestic flight? Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded

Yes

City of Origin First Airport of Entry

QATAR CHENNAI AIRPORT

First Airport of Entry State/Union Territories Final Destination - House Number

TAMIL NADU 10/142

Final Destination Street/Village Final Destination Tehsil

RIVER SIDE STREET CUDDALORE PORT

Final Destination State/Union Territories Final Destination District/City

TAMIL NADU CUDDALORE

Final Destination Pincode Contact Number

607003 +919952862002

Alternate Contact Number Email ID

STHAIYUB44@GMAIL.COM

Fever Diabetes
No No
 Cough Hypertension
No No

Respiratory Distress Bronchial Asthma

No No

Cancer
No

Unde Immunosuppresive Therapy

No

Post Transplant Patients

No

Details of the Cities / Countries visited in last 14 days? How many passengers are travelling?
DOHA 1

I/We have agreed to the following terms:

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

The above information is correct and in case of any wrong information and non-cooperation, I will be liable for action
under the law. I also agree to the terms & conditions.

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