Declaration Form

Entry Declaration - Declaration Form

ARRIVAL HEALTH DECLARATION (FOR RETURNING BRUNEI CITIZENS AND PERMANENT RESIDENTS

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:

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.

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):

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.)