Traveler Disclosure and Attestation – flights to the United States

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U.S. CDC requirement: every person boarding a flight to the United States must confirm that they have not been in the Democratic Republic of the Congo (DRC) in the 21 days before boarding. One form per person. A parent or guardian completes a separate form for each child under 18.

Important – check your flight date

You can only complete this form for a flight from 24 hours before departure until check-in closes (60 minutes before departure). Select the flight and date shown on your ticket: a form completed for another flight or date is not valid and must be completed again.

1. Flight and traveler

Flight Traveler is

Select your flight to see the departure date and time.

I confirm that the traveler flies on the flight and departure date shown above.

Booking reference (PNR) Passenger type

Staff number Duty

Surname (as in travel document) Given name(s) Date of birth

2. Who completes this form?

The traveler (adult) – for myself An authorized representative (parent, guardian or other authorized person) – required for children under 18 and for persons who cannot act on their own behalf

Name of authorized representative Relationship

3. Disclosure – please read

Presence in the Democratic Republic of the Congo (DRC) means any physical presence in the DRC by air, land or sea, including connecting through an airport in the DRC, even if you did not leave the airport or the aircraft. Flying over the DRC does not count. The 21 days are counted in calendar days: the day you left the DRC is day 0; boarding a flight to the United States is allowed from day 22.

Has the traveler been physically present in the Democratic Republic of the Congo (DRC) in the 21 days before boarding this flight?

No Yes

Date the traveler left the DRC

NOT ELIGIBLE TO BOARD – presence in the DRC reported within 21 days. Surinam Airways will deny boarding to this passenger on flights to the United States before the date below, unless a U.S. Government exemption applies. Please contact Surinam Airways to change your booking.

Option 1 – I attest that I have not been present in the Democratic Republic of the Congo during the 21 days before boarding a flight to the United States.

Option 2 – I am authorized to act on behalf of the traveler named on this form, and I attest that this person has not been present in the Democratic Republic of the Congo during the 21 days before boarding a flight to the United States.

4. Confirmation and signature

I have read the disclosure above. The information I have given is true and accurate. I understand that willfully providing false or misleading information may lead to criminal fines and imprisonment under 18 U.S.C. § 1001. Type your full name as signature (traveler, or representative if Option 2)

Airline staff may help with data entry but may not attest or sign on behalf of the traveler. Privacy: this information is collected for the U.S. Centers for Disease Control and Prevention for public health purposes. Surinam Airways keeps it for at least 42 days after arrival in the United States and then deletes it.