1. Declaration of Travel History of seafarer (past 28 days)
Name : Hitesh Nandkishor Dhanu
Last sign off date- 13/06/2022
Last sign off port/country: DUBAI
Passport no.- R6580397
Indos no.- 18GL1196
S. No. Date Details / address of place visited (Home, Friend, Hotel, Social gathering, Hospitals etc.)
Approx. time
of visit to
place(s) Hrs
Name of the
person(s) you met
with
Contact details (phone
no.) of person(s) met
01 23-09-2022 Mangelwad, Umbergaon Dist Valsad Gujarat 396170 28 days Family 7383839179
I / we, do hereby declare that above particulars of information and facts stated are true, correct and complete to the best of my knowledge and belief.
Place: Mumbai Hitesh Nandkishor Dhanu
Name/Sign_______________________________________________
Date:______________________________ NAME / SIGN