REGISTRATION FORM FOR CITIZENS OF MEGHALAYA STRANDED OUTSIDE INDIA

Personal Details
Name:

Surname:

Gender:
Male Female Others

Date Of Birth:

Age:

Mobile Number:
Email:

Parent/Guardian/Emergency Contact:

ID Proof:

Document Type Allowed (jpg,jpeg and png only) and size(Max 500KB)

Language:
Details of Current Location (Country):
Select Country:

City:

Address:

Do You intend to return?
Yes No

Place Of Stay (In Meghalaya):
District:

Select Urban/Rural
Rural Urban

Select Municipal Board/Town Committee

Block:

Village/Town:

Locality:

Address:

Details of the Journey:
(This section can be filled when you have the travel details)

Mode of Travel:

Flight No./Train No.:

How many People are with you?

Port of Entry in India:

Entry into Meghalaya from:

Plan date of arrival:
In India:

In Meghalaya:


Do You Have the following symptoms?
Fever
Yes No

Cough
Yes No

Breathing Difficulties
Yes No

Since when have you had these Symptons?