GENERAL DECLARATION
ICAO ANNEX 9
APPENDIX 1
(OUTWARD / INWARD)
Operator Air Asia - Indonesia QZ20
Marks of Nationality and Registration PK-AZA Flight QZ474 Date 19/Apr/24
Departure from JAKARTA, SOEKARNO HATTA INTL(INDONESIA) Arrival at PHNOM PENH INTL(CAMBODIA)
FLIGHT ROUTING
("Airport:" Column always to list origin, every en-route stop and destination)
AIR PS NAME* GEN PASSPORT PASSP BIRTH NTLY NO. OF PASSENGERS
PORT DER NUMBER EXPIRY DATE ON THIS STAGE**
CGK CP TRI HANGGONO KHARIS M X998963 02/12/25 07/08/72 IDN Departure Place: CGK
to FO GERHANA NUR SAHARA PUTRI F X2029779 28/04/33 16/01/96 IDN ......................
PNH FO NICOLAUS BONAVENTURA SETITIT M X2259352 12/09/33 03/03/83 IDN Embarking:
......................
SC DICKY HUDIANDY M X1497302 30/04/34 23/09/88 IDN Through on same flight
CC AFIFAH MAYA AUDITA F E2507690 10/04/33 23/04/94 IDN ......................
CC IRIANI TAHIR LEBU F X1844121 24/11/32 28/05/95 IDN Arrival Place: PNH
CC MUHAMMAD ADAM GHAZALI M E2543561 08/03/33 28/02/99 IDN ......................
JS EDWAR ANDY ZULMI M E6740735 07/03/34 21/07/88 IDN Disembarking:
JS NOFITRA ARESI M E0004153 09/08/27 16/11/85 IDN ......................
Through on same flight
......................
DECLARATION OF HEALTH FOR OFFICIAL USE
Name and seat number or function of persons on board with illnesses other than
airsickness or the effects of accidents , who may be suffering from a communicable ONLY
disease (a fever-temperature 38°C/100°F or greater-associated with one or more of the
following signs or symptoms, e.g. appearing obviously unwell; persistent coughing;
impaired breathing; persistent diarrhea; persistent vomiting; skin rash; bruising
or bleeding without previous injury; or confusion of recent onset, increases the
likelihood that the person is suffering a communicable disease) as well as such cases
of illness disembarked during a previous stop........................................
.....................................................................................
Details of each disinsecting or sanitary treatment (place, date,time, method) during
the flight. If no disinsecting has been carried out during the flight, give details
of most recent disinsecting.........................................................
....................................................................................
Signed, if required, with time and date ....................................
Crew Member concerned
I declare that all statements and particulars contained in this General Declaration and in any supplementary forms required to be
presented with this General Declaration are complete, exact and true to the best of my knowledge and that all through passengers
will continue/have continued on the flight.
Signature...........................................................................
Authorized Agent or Pilot-In-Command
Delete as necessary
* To be completed when required by the State.
** Not to be completed when passenger manifests are presented and to be completed only when required by the State.
