Airport Self-Declaration Form

Full Name

First NameLast Name

Date of Birth

Date

Nationality

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Flight Number

Date of Arrival or Departure

Date

Seat Number (if applicable)

Address During Stay (Hotel or Residence)

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Have you traveled internationally in the last 14 days?

If yes, please list countries visited in the last 14 days

Are you currently experiencing any of the following symptoms? (Select all that apply)

Have you been in close contact with anyone diagnosed with a communicable disease (such as COVID-19, influenza) in the last 14 days?

Emergency Contact Name and Phone Number

Signature (Please sign below to confirm your declaration)