Self Reporting 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
@
SR1012617278

Name Date of Birth

ABDUSSALEEM 15/05/1971

Flight Number Seat Number

SG141 NIL

PNR Number Nationality

VJ1Z7R India

Passport Number Passport Copy Uploaded

P1750718 Yes

Date of Arrival Country of Origin

17/10/2020 United Arab Emirates

City of Origin First Airport of Entry

DUBAI Calicut Airport

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

Kerala TIRURANGADI

Final Destination Street/Village Final Destination Tehsil

TIRURANGADI

Final Destination State/Union Territories Final Destination District/City

Kerala MALAPPURAM

Final Destination Pincode Contact Number

676306 +919656030275

Alternate Contact Number Email ID

sakeer369@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?
Umm al Quwain 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 would undergo mandatory quarantine for 14 days i.e. 7 days paid institutional quarantine at my own cost, followed by 7
days isolation at home with self-monitoring of health.