Declaration Form

ARRIVAL HEALTH DECLARATION (FOR RETURNING BRUNEI CITIZENS AND PERMANENT RESIDENTS)

ARRIVAL HEALTH DECLARATION (FOR RETURNING BRUNEI CITIZENS AND PERMANENT RESIDENTS OR FOREIGNERS ARRIVING FROM TRAVEL GREEN LIST COUNTRIES)

1. PERSONAL INFORMATION

Nama (seperti tertera dalam Pasport):*
Name (as appears in passport):

Gender:*
Jantina:

Tarikh Lahir:*
Date of Birth:

Nombor Pasport:*
Passport number:

Tarikh mansuh Pasport:*
Date of passport expiry:

Tarikh Pasport dikeluarkan:*
Date of Passport Issuance:

Nombor IC (bagi yang berumur 12 tahun ke atas):
IC Number (above 12 years old):

Warganegara:*
(Nationality):

Nombor Kontak:*
Contact Number:

Alamat E-mel:*
Email Address:

HUBUNGAN LAIN DI NEGARA BRUNEI DARUSSALAM (OTHER CONTACT IN BRUNEI DARUSSALAM)

Nama:*
Name:

Nombor Telefon:*
Phone Number:

2. TRAVEL INFORMATION

Tarikh ketibaan di Negara Brunei Darussalam:*
Date of Arrival in Brunei Darussalam:

Negara terakhir tempat berlepas:*
Last Country of Disembarkation:

Negara-negara yang telah dikunjungi dalam tempoh 14 hari sebelum tarikh ketibaan di Negara Brunei Darussalam termasuk transit:*
Countries visited during 14 days prior to arrival in Brunei Darussalam including transit:

Jenis Pengangkutan :*
Mode of Travel:

Nombor Pengangkutan yang digunakan (seperti no. penerbangan):*
(AIR (flight no: ) / LAND (vehicle no: ) / SEA (vessel name: )

Alamat rumah di Negara Brunei Darussalam:*
Home Address in Brunei Darussalam (Full address of home or hotel):

Tujuan Masuk:*
(Purpose of Entry):

Tujuan perjalanan semasa berada di luar Negara Brunei Darussalam:
Purpose of Travel Outside Brunei Darussalam:

Jumlah Orang Jika Berjalan Sekumpulan:*
How many people are you traveling with?:

Tarikh berlepas dari Negara Brunei Darussalam (jika berkenaan):
Date of Departure from Brunei Darussalam (if applicable):

Kategori Perjalanan :*
Travel Category:

Hotel penginapan bagi tujuan pengasingan diri:*
Declared hotel accommodation for purposes of self-isolation :

Nota: Hotel penginapan hendaklah ditempah sebelum tarikh ketibaan di Negara Brunei Darussalam. Penjamin/Pemohon hendaklah menghubungi hotel-hotel bagi mendapatkan kadar terkini dan membuat tempahan penginapan. Adalah dinasihatkan untuk membuat tempahan selama 6 hari minima. Tempoh pengasingan diri adalah diantara 2 ke 14 hari tertakluk kepada penilaian risiko kesihatan setelah tiba di Negara Brunei Darussalam.

Note: Hotel accommodation must be reserved before intended date of arrival in Brunei Darussalam. Sponsor/Applicant are required to contact hotels directly to seek information on respective prevailing hotel rates and to proceed with making reservations. It is advised to make a booking of a minimum 6 days. Period of isolation may be 2-14 days depending on health risk assessment upon arrival.

3. COVID-19 VACCINATION DETAILS

Nota: Sila muatnaik sijil vaksinasi COVID-19 jika tidak tertera dalam aplikasi BruHealth.

Note: To upload copy of covid-19 vaccination certificate if not already on BruHealth.

Status Vaksinasi COVID-19:*
(COVID-19 Vaccination Status):

Jenis Vaksinasi COVID-19:*
(COVID-19 Vaccination Type):

4. COVID-19 STATUS

Tarikh ujian swab di jalani sebelum berlepas ke Negara Brunei Darussalam:*
Date swab taken before departure to Brunei Darussalam:

Keputusan Ujian Swab:*
Result of Swab:

Pernah kah mendapat keputusan ujian Positif?:*
Have you ever tested Positive for Covid-19?:

Pernah berhubung dengan individu yang didapati positif dengan Covid-19 dalam tempoh 14 hari lepas?:*
Have you or anyone else your travel party been in close contact with anyone who has been Covid-19 positive in the last 14 days?:

Telah memperolehi keputusan ujian COVID-19 PCR sebelum berlepas*
Obtained pre-departure COVID-19 PCR Test Result:

Nota: Jika keputusan ujian COVID-19 telah diperolehi, adalah dikehendaki untuk menunjukkannya kepada pihak-pihak berkuasa setelah tiba di Negara Brunei Darussalam.
Note: If a COVID-19 Test result has been obtained, you are required to present this to authorities upon arrival in Brunei Darussalam.

Nota: Sila muatnaik keputusan ujian PCR jika ada.
Note: To upload copy of pre-departure PCR swab result if available.

Employer / Sponsor (for foreign nationals holding a Brunei immigration pass)

Nama wakil organisasi / majikan untuk dihubungi:
Agency's individual contact name:

Nota: Hanya diperlukan bagi mereka yang telah membuat perjalanan keluar Negara Brunei Darussalam di atas urusan rasmi / pertugasan.

Note: Only applicable to those who had travelled outside Brunei Darussalam on official or duty travel.

Nombor telefon (bimbit):
Phone Number (mobile):

Nota: Wakil hendaklah dapat dihubungi pada setiap masa.

Note: Contact person must be available to be called at all times.

Alamat e-mel:
E-Mail Address:

Saya akui bahawa maklumat yang dilengkapkan adalah tepat dan mengambil maklum bahawa memberikan maklumat palsu deklarasi kesihatan merupakan kesalahan di bawah Akta Penyakit-Penyakit Berjangkit, Penggal 204, di mana boleh dikenakan denda sebanyak $10000 atau penjara 6 bulan atau kedua-duanya sekali.

(I declare that the above information is correct and i acknowledge that any false or misleading information is in contravention with the Infectious Disease Act Cap 204, where the penalty is a fine of up to $10000 or imprisonment of up to 6 months or both.)

Saya berjanji untuk mematuhi peraturan-peraturan kesihatan setelah tiba di Negara Brunei Darussalam.

(I will comply with all the health requirements upon arrival in Brunei Darussalam.)