Passenger Locator Form

STATUS: AMBER
VACCINE STATUS: DECLARED FULL/EXEMPT

The code contains personal

information. By sharing the code,
you will be sharing your passenger
locator form data.

Summary
Name Constance Mary Cooke
Passport number 528807846
What is the flight number, train number or ship FR4967
name that you will arrive on?
Reference UKVI_5ZAA015570296
Status AMB
What are your travel plans? Stay in the UK
Are you required to self-isolate when you arrive in I meet the vaccine eligibility criteria
the UK?
Are you required to book a COVID-19 test Yes
package for when you arrive in the UK?
Your test package booking reference RANDX3130955
Arrival location London Stansted Airport (STN)
Date of arrival 23 September 2021 16:10 British Summer Time
(BST)
Date of submission 22 September 2021 10:56 British Summer Time
(BST)

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 UK Visas & Immigration

Personal information

Email address conniecooke123@icloud.com

Travel information

Do you have an address for where you will stay Yes

during your first 10 days in the UK?

You provided the following address as your Yes

residential address. Do you plan on staying at this
address?
6 RIVERDALE PARK
BALLYCLARE
BT399DG

What address will you stay at for your first 10 days 6 RIVERDALE PARK
in the UK? BALLYCLARE
BT399DG

When will you arrive there? 23 September 2021

Are you required to self-isolate when you arrive in I meet the vaccine eligibility criteria
the UK?

What are your travel plans? Stay in the UK

Where will you arrive in the UK? London Stansted Airport (STN)

What country are you travelling from? Italy

What is the name of the company? Ryanair

What is the flight number, train number or ship FR4967

name that you will arrive on?

What is your seat number? 3

Which countries have you been in, or will you be in, Italy
for the 10 days before coming to the UK?

Have you visited, or will you visit, any islands in this No

country during the 10 days before you arrive in the
UK?

Arrival date 16 September 2021

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 UK Visas & Immigration
Departure date 23 September 2021

Are you required to book a COVID-19 test package Yes

for when you arrive in the UK?

Your test package booking reference RANDX3130955

Are you using Test to Release? No

Your dates of travel

When do you plan to arrive in the UK? 23 September 2021 16:10 PM

Personal information

Given name(s) Constance Mary

Family name / Surname Cooke

What is your sex? Female

Is your home address in the UK? Yes

Home address 6 RIVERDALE PARK

BALLYCLARE
BT399DG
(address verified)

How can we contact you when you are in the UK? I can be contacted by phone call and text message
(SMS)

Date of birth 28 June 1962

Your primary phone number +44 7876456780

Do you meet the COVID-19 vaccination eligibility Yes

criteria for reduced isolation and testing
requirements?

Do you have a QR code that you can scan to verify No

your vaccination status?

Have you provided proof of your vaccination No

status?

Have you been fully vaccinated from COVID-19? Yes

Which country did you receive your COVID-19 England (United Kingdom of Great Britain and

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 UK Visas & Immigration
vaccination(s) in? Northern Ireland)

Passport and travel document details

Passport number or travel document reference 528807846

number

Country of Issue British Citizen (GBR)

Expiry date 4 November 2024

People you are travelling with

Are you travelling to the UK with anyone under 18 No

years old that you are including on this form?

Declaration
I declare that:

I will arrive in the UK within the next 48 hours

I understand I have to provide proof of a negative COVID-19 test prior to departure to the UK (unless I am
exempt)
I understand that I must bring proof of my COVID-19 vaccination status if I meet the eligibility criteria
I have provided my seat number, if relevant
The information I have entered in this form is correct
I understand it could be a criminal offence to provide false details and I may be prosecuted

If any of your information changes once you have submitted your form, such as travel details, seat number, or
contact information, you must complete a new form.

I confirm that I understand and agree with the above declarations.

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