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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
@
SR0830165595

Name Date of Birth


KUSAMPUDI YOGESH MANIKANTA 12/03/1996

Flight Number Seat Number


6117 5F

PNR Number Nationality


JG1M2S India

Passport Number Passport Copy Uploaded


T8543990 Yes

Date of Arrival Country of Origin


01/09/2020 South Africa

City of Origin First Airport of Entry


Johannesburg Mumbai Airport

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


Maharashtra Sri Sai Ram Towe

Final Destination Street/Village Final Destination Tehsil


Youth Club Road, Pedamiram Kalla

Final Destination State/Union Territories Final Destination District/City


Andhra Pradesh Pedamiram

Final Destination Pincode Contact Number


534204 +919704517333

Alternate Contact Number Email ID


+919704331111 yogeshvarma29@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?
Johannesburg,South Africa 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.

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