ETP Registration Form

JENIS PERJALANAN DAN LALUAN (TRAVEL TYPE AND ROUTE)

Jenis Perjalanan:*
(Travel Type):

Negara Asal Tempat Berlepas:*
(Origin Departure Country):

Negara Transit/ Tempat Terakhir Berlepas:*
(Transit Country/Last Place Of Embarkation):

MAKLUMAT SYARIKAT/INDIVIDU/AGENSI YANG MENJAMIN (SPONSOR'S DETAILS)

Nama Syarikat / Individu / Agensi:*
(Company / Individual / Agency Name):

Alamat penjamin:
(Sponsor’s address):

No. Telefon:*
(Phone Number):

Nota: No. Telefon yang dapat dihubungi pada bila-bila masa
Note: Phone Number that is available for contact at any time

Alamat E-mel:*
(E-Mail Address):

MAKLUMAT FOKAL INDIVIDU YANG BOLEH DIHUBUNGI (FOCAL PERSON CONTACT DETAILS)

Nama fokal individu:*
(Focal individual name):

No. Telefon:*
(Phone Number):

Alamat E-mel:
(E-Mail Address):

KETERANGAN INDIVIDU YANG DIPOHONKAN (APPLICANTS DETAILS)

Nama (Seperti di dalam Passport):*
(Name as appears on Passport):

Tarikh Lahir:
(Date of Birth):

Warganegara:*
(Nationality):

No. Pasport:*
(Passport Number):

Tarikh Mansuh Pasport:*
(Date of Expiry):

Tarikh Pasport Dikeluarkan:
(Date of Passport Issuance):

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

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

Sila muatnaik sijil vaksinasi COVID-19 di laman seterusnya. Please attach COVID-19 vaccination certificate in the next page.

KETERANGAN PEMOHON (APPLICATION DETAILS)

Tarikh Masuk Ke Brunei Darussalam:*
(Date of Entry to Brunei Darussalam):

Tujuan Masuk:*
(Purpose of Entry):

Kelamaan Tempoh Tinggal Yang Dipohonkan:*
(Intended Duration of Stay):

Tempat pengasingan diri setelah tiba di Negara Brunei Darussalam:*
(Isolation place once arrived in Brunei Darussalam):

Saya mengaku dan mengesahkan bahawa individu yang dipohonkan telah berada di tempat terakhir dan adalah dalam keadaan yang sihat sebelum Tiba Di Negara Brunei Darussalam selama 14 Hari.

(I declare and assure that the intended traveler will have been in good health and remained in the country of disembarkation for 14 days prior to arrival in Brunei Darussalam.).