REGISTRATION FORM FOR INDIVIDUALS STRANDED IN MEGHALAYA

Those who do not have Internet access may also call 1070 between 9 am and 8 pm on any day.

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:
Place Of Stay (In Meghalaya):
District:

Select Urban/Rural
Rural Urban

Select Municipal Board/Town Committee

Block:

Village/Town:

Locality:

Address:

Do You intend to leave?
Yes No

Destination Details (Outside Meghalaya):
State:

District:

Postal Address:

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

Plan mode of Travel:

Vehicle No.:

How many People are with you?

Exit Meghalaya from:

Plan date of departure:

Do You Have the following symptoms?
Fever
Yes No

Cough
Yes No

Breathing Difficulties
Yes No

Since when have you had these Symptons?