SR2104210450857 PDF

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Summary

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Description

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

@

SR2104210450857

Name

Date of Birth

HARMANPREET KAUR

08/10/1995

Flight Number

Seat Number

AC42

32B

PNR Number

Nationality

2CJAIQ

INDIA

Passport Number

Passport Copy Uploaded

R5833641

Yes

Date of Arrival

Country of Origin

23/04/2021

CANADA

Are you taking a connecting Domestic flight?

Domestic Connecting Flight

NO

RT-PCR Negative Certificate Uploaded Yes

City of Origin

First Airport of Entry

DELHI

DELHI AIRPORT

First Airport of Entry State/Union Territories

Final Destination - House Number

NEW DELHI

56

Final Destination Street/Village

Final Destination Tehsil

NAWAN PIND GATEWALA

KAPURTHALA

Final Destination State/Union Territories

Final Destination District/City

PUNJAB

KAPURTHALA

Final Destination Pincode

Contact Number

144601

+12269724848

Alternate Contact Number

Email ID [email protected]

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?

NO WHERE

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....