Instructions for Public Health Passenger Locator Form (English)
Your information is intended to be held in accordance with privacy laws and used only for public health purposes. Complete one form per family. Please write clearly within the boxes. Print in capital (uppercase) letters. Put only one letter or number per box. Keep boxes blank for spaces between words or between numbers and words. Please fill out completely and accurately.
Flight
information, Questions 1-4:
airline name, flight number, seat number (row and letter where you
actually sat during the flight) and
date of arrival (2-digit
day, 2-digit month, 4-digit year; example: 30 09 2011)
Personal information, Questions 5-8: Last (family) name, first (given) name, middle initial; check male or female
Contact information, Questions 9-13: Telephone numbers where you can be reached during your trip: mobile, business, home, other phone numbers (include country and city codes); and email address (if any)
Permanent address, Questions 14-19: (where you live most of the year) house number and street name, apartment number (if any), city, state or province, country, ZIP or postal code
Temporary address, Questions 20-26: (If you are a visitor, or if you will be at an address other than your permanent home, use the address where you will be staying. Only list the first address.) If staying at a hotel, please include the name. House or building number and street, apartment number (if any), city, state or province, country, ZIP or postal code
Emergency contact, Questions 27-33: (someone who can reach you in the next 30 days) Last (family) name, first (given) name, city, country, email address (if any), mobile and other phone numbers (include country and city codes)
Travel
companions (family), Question 34:
On same flight—Last (family) name, first (given) name, seat
and row number, and
age if younger than 18 years
Travel
companions (non-family), Question 35: On
same flight—Last (family) name, first (given) name;
or
name
of your group, if any
(business, music, or tour group; sports
team or other)
Note: Instructions will be translated into 2 other languages on this same page (3 more translations on back side; total of six). Translations to be done by ICAO
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Karen Marienau |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |