Page 3 - surat-pernyataan-perjalanan-covid--19

TRAVEL DECLARATION IN ORDER TO CONTROL COVID-19 IN INDONESIA

Full Name …………………………………………………………………………….
:
Nationality : …………………………………………………………………………….
Domicile : City ………………………... /Country .……………………….….
Date of Departure : ………………………………………………….…………………………

Flight Number & Destination : JT/IW/ID*** - …………….. to ……..………………………..
Date of Return Flight * : ……………………………………………………………………….…..

: ……………………………………………………………………………
International or Domestic Connecting Flight **

th
* Return Flight shall be made before May 24 , 2020 (Eid-al-Fitr), to be filled by Indonesian or Foreign Citizens
domiciled in Indonesia.
** Specially filled out by Indonesian/Foreign Citizens who will return to their country/domicile
(repatriation).
*** Cross the unnecessary ones.

Purpose of Travel : (Statement /Reference Letter is attached )

Heads of the Highest State Institutions of the Republic of Indonesia or State Visit
Operational of Embassies, General Consulate, and Foreign Consulates as well as Representatives of
international organizations in Indonesia
Operational repatriation (repatriation flight) for the repatriation of Indonesian Citizens and Foreign
Citizens, and Students
Operational of law enforcement, order and emergency services
Other operations (with permission from the General Director of Civil Aviation) : ………..……………………
A business person, or individual trader that is not in the context of “going home”
Travel for the needs of the sick or grieving

Health Condition :
Yes No
Direct contact with individual suspected or tested positive for Covid-19 in the last 14 days
Has conducted Covid-19 Test with negative results (Health Certificate/ Certificate stating free from
Covid-19 as attached - Attach medical certificate from a doctor, hospital, or other medical facility)

I declare that the above statement I made above is true and accurate, and I hereby release LION AIR
GROUP (Lion Air/Batik Air/Wings Air) from any legal claim, suit, liability and/or losses arising from
incorrectness or inaccuracy of my statement and/or any incompliance with the Ministry of Transportation
Regulation PM Number 25 of 2020 regarding Transportation Control during the Eid-al-Fitr 1441 H Mass
Exodus Period as means to prevent the transmission of Covid-19.

Special Check List Filled by Airport Check-In Officers
…………………………………… / …… / …… / 2020
Certificate and Official Travel Schedule
Covid-19 free Health Certificate valid for 7 days
Declaration known form the Head of Village Head
Patient Reference Letter / Death Certificate
Agency / Institution Certificate (Repatriation of Workers /

Indonesian Citizens / Foreigners)
( ______________________________ ) School / University Certificate (Student Repatriation)
Signature & Full Name Fill out the Health Alert Card (HAC)
Have a Return Flight Reservation / Ticket