Guest Self Declaration Form

Guest Self Declaration Form
Date

Day Month Year
Date
Guest Name
Gender
Contact details(Mobile no)
Date of Birth

Day Month Year
Date
Email ID *
example@example.com
Nationality
Permanent Address,
Coming from (with details of destination and route)
Going to (with details of destination and route)
Mode of transportation while going back with details of flight/ train
Arrival date

Day Month Year
Date
Arrival Time

: Hour Minutes AM/PM Option
Checkout Date

Day Month Year
Date
Check Out Time

: Hour Minutes AM/PM Option
Purpose of visit (Optional)
Travel history
Have you been to any red zone / affected countries or area(s) in the past 14 days? *

Yes No
Have you been in contact with people being infected or diagnosed with COVID 19 *

Yes No
Have you been a confirmed COVID-19 patient? *

Yes No
Have you been asked to go for home quarantine by an authority or medical practitioner? *

Yes No
If Yes, Please Enter Details

Are you experiencing any of the symptoms listed below? *

Yes

Fever

Dry Cough

Shortness of Breath

Persistent Pain in Chest

Runny Nose

Sore Throat

Headaches

Breathing Difficulty

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