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Submission: On February 20 via manual from US — Scanned from DE
Submission: On February 20 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="onda"><input type="hidden" name="nccharset" value="C081E625">
<div class="form-header"><img src="/extension/onda_design/design/onda_design/images/header3.png" alt="">
<div class="header-title">
<br><br><br>
<p><strong>البطـــــاقة الصـــــحية للمســـــافر</strong></p>
<p class="bold">FICHE SANITAIRE DU PASSAGER / PUBLIC HEALTH PASSENGER FORM </p>
<br>
</div>
</div>
<div align="center" style="border-style: solid;">
<p text-align="center"> ﻫﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ ﻣﺨﺼﺼﺔ ﻟﻠﺴﻠﻄﺎﺕ ﺍﻟﺼﺤﻴﺔ ﻟﺘﻤﻜﻴﻨﻬﺎ ﻣﻦ ﺍﻟﺘﻮﺍﺻﻞ ﻣﻌﻜﻢ ﺇﺫﺍ ﻟﺰﻡ ﺍﻷﻣﺮ، ﻭ ﺫﻟﻚ ﻓﻲ ﺣﺎﻟﺔ ﺭﺻﺪ ﻣﺮﺽ ﻣﻌﺪ ﻟﺪﻯ ﻣﺴﺎﻓﺮ ﻋﻠﻰ ﻧﻔﺲ ﺭﺣﻠﺘﻜﻢ. ﺳﺘﺒﻘﻰ ﺑﻴﺎﻧﺎﺗﻜﻢ ﺳﺮﻳﺔ ﻭﺳﻴﺘﻢ ﺇﺗﻼﻓﻬﺎ ﺑﻌﺪ 3 أشهر. </p>
<hr style="width:80%">
<p text-align="center"> Ce document est destiné aux autorités sanitaires afin de vous contacter en cas de détection d’un cas de maladie transmissible chez un passager relevant du même vol/ traversée et vous assurer la prise en charge adéquate.
Vos données resteront confidentielles et seront détruites après 3 mois. </p>
<hr style="width:80%">
<p text-align="center"> This document is intended for the health authorities in order to contact you in case of detection of a transmissible disease in a passenger on the same flight/crossing and to ensure an appropriate treatment. Your
information will remain confidential and will be destroyed after 3 months. </p>
</div>
<br>
<div class="form-content">
<h3 class="underline">INFORMATIONS CONCERNANT LE VOL/ FLIGHT INFORMATION</h3>
<div class="form-ligne">
<label for="" class="label-form">Date d’arrivée / Arrival Date:<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="1" class="form-carriere-text" required="required">
<label for="" class="label-form"><span class="required">*</span>:تاريخ الوصول</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">Numéro De Siège que vous occupiez / Seat Number that you occupied:<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="2" class="form-carriere-text default">
<label for="" class="label-form"><span class="required">*</span>:رقم المقعد الذي كنتم تشغلونه</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">Numéro De Vol / Flight Number :<span class="required">*</span> </label>
<input type="text" name="FORM_CRR_PRENOM" id="3" class="form-carriere-text" required="required">
<label for="" class="label-form"><span class="required">*</span>:رقم الرحلة</label>
</div>
<h3 class="underline">INFORMATIONS SUR LE PASSAGER/ PASSENGER INFORMATION</h3>
<div class="form-ligne">
<label for="" class="label-form">Nom Prénom / Full Name:<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="4" class="form-carriere-text" required="required">
<label for="" class="label-form"><span class="required">*</span>:الإسم العائلي و الشخصي</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">N° de la CNIE ou CI/ ID card N° or residence permit N° :<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="6" class="form-carriere-text">
<label for="" class="label-form"><span class="required">*</span>:رقم البطاقة الوطنية أو رقم بطاقة الإقامة</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">N° passeport/ Passport number :<span class="required">*</span> </label>
<input type="text" name="FORM_CRR_PRENOM" id="7" class="form-carriere-text" required="required">
<label for="" class="label-form"><span class="required">*</span>:رقم الجواز</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">Adresses au Maroc/ Addresses in Morocco:<span class="required">*</span></label>
<textarea rows="3" id="adress" name="adress"></textarea>
<label for="" class="label-form"><span class="required">*</span>:العنوان في المغرب</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">N° de téléphone hors Maroc/ Phone N° outside Morocco :<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="tel" class="form-carriere-text">
<label for="" class="label-form"><span class="required">*</span>:رقم الهاتف خارج المغرب</label>
</div>
<div class="form-ligne">
<label for="" class="label-form">N° de téléphone au Maroc/ Phone N° in Morocco:<span class="required">*</span></label>
<input type="text" name="FORM_CRR_PRENOM" id="tel1" class="form-carriere-text">
<label for="" class="label-form"><span class="required">*</span>:رقم الهاتف داخل المغرب</label>
</div>
</div>
<div class="signe">
<p>أصرح بصحة جميع المعلومات المدلى بها.</p>
<p>Je déclare que toutes les informations sont correctes.</p>
<p>I declare that all the informations are true and correct.</p>
<div class="signature-wrapper">
<div class="signature"><label>Signature :</label></div>
<div class="signature"><label>التوقيع:</label></div>
</div>
<br><br>
<p text-align="center">Date :</p>
<hr>
<p>شكرا على حسن تفهمكم</p>
<p>Merci pour votre compréhension</p>
<p>We appreciate your kind understanding</p>
</div>
<div class="signe">
<p>Réservé à l’administration / Reserved for administration/خاص بالإدارة</p>
<div class="form-ligne">
<label for="" class="label-form">N° d’admission: </label>
</div>
</div>
<p style="font-style: italic"><span class="required">*</span> Champs obligatoires</p>
<div class="btn-wrapper">
<button id="print" style="cursor: pointer">Renseigner et Imprimer</button>
</div>
</form>Text Content
البطـــــاقة الصـــــحية للمســـــافر FICHE SANITAIRE DU PASSAGER / PUBLIC HEALTH PASSENGER FORM ﻫﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ ﻣﺨﺼﺼﺔ ﻟﻠﺴﻠﻄﺎﺕ ﺍﻟﺼﺤﻴﺔ ﻟﺘﻤﻜﻴﻨﻬﺎ ﻣﻦ ﺍﻟﺘﻮﺍﺻﻞ ﻣﻌﻜﻢ ﺇﺫﺍ ﻟﺰﻡ ﺍﻷﻣﺮ، ﻭ ﺫﻟﻚ ﻓﻲ ﺣﺎﻟﺔ ﺭﺻﺪ ﻣﺮﺽ ﻣﻌﺪ ﻟﺪﻯ ﻣﺴﺎﻓﺮ ﻋﻠﻰ ﻧﻔﺲ ﺭﺣﻠﺘﻜﻢ. ﺳﺘﺒﻘﻰ ﺑﻴﺎﻧﺎﺗﻜﻢ ﺳﺮﻳﺔ ﻭﺳﻴﺘﻢ ﺇﺗﻼﻓﻬﺎ ﺑﻌﺪ 3 أشهر. -------------------------------------------------------------------------------- Ce document est destiné aux autorités sanitaires afin de vous contacter en cas de détection d’un cas de maladie transmissible chez un passager relevant du même vol/ traversée et vous assurer la prise en charge adéquate. Vos données resteront confidentielles et seront détruites après 3 mois. -------------------------------------------------------------------------------- This document is intended for the health authorities in order to contact you in case of detection of a transmissible disease in a passenger on the same flight/crossing and to ensure an appropriate treatment. Your information will remain confidential and will be destroyed after 3 months. INFORMATIONS CONCERNANT LE VOL/ FLIGHT INFORMATION Date d’arrivée / Arrival Date:* *:تاريخ الوصول Numéro De Siège que vous occupiez / Seat Number that you occupied:* *:رقم المقعد الذي كنتم تشغلونه Numéro De Vol / Flight Number :* *:رقم الرحلة INFORMATIONS SUR LE PASSAGER/ PASSENGER INFORMATION Nom Prénom / Full Name:* *:الإسم العائلي و الشخصي N° de la CNIE ou CI/ ID card N° or residence permit N° :* *:رقم البطاقة الوطنية أو رقم بطاقة الإقامة N° passeport/ Passport number :* *:رقم الجواز Adresses au Maroc/ Addresses in Morocco:* *:العنوان في المغرب N° de téléphone hors Maroc/ Phone N° outside Morocco :* *:رقم الهاتف خارج المغرب N° de téléphone au Maroc/ Phone N° in Morocco:* *:رقم الهاتف داخل المغرب أصرح بصحة جميع المعلومات المدلى بها. Je déclare que toutes les informations sont correctes. I declare that all the informations are true and correct. Signature : التوقيع: Date : -------------------------------------------------------------------------------- شكرا على حسن تفهمكم Merci pour votre compréhension We appreciate your kind understanding Réservé à l’administration / Reserved for administration/خاص بالإدارة N° d’admission: * Champs obligatoires Renseigner et Imprimer word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word word mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1 mmMwWLliI0fiflO&1