Palau Entry Form

The information bellow must be completed by all person Entering Palau. Print the Answer to all questions In blue or black ink.

Surname, First Name

Email*

Airline / Vessel No.

Passport Number

Arrival Date (Month / Day / Year)

Country of Passport

City of Residence

Palau Residents fill out blackside only

How many times have you been to Palau?

First Time
2 Times
3 Times
4 Times or more

Purpose of Travel (Check all that apply)?

How did you book your trip?

Package Includes (Check all that apply):

Airfare
Dinners
Lodging
Activities

Accommodations in Palau:

How did you hear about Palau?

What is your Country of residence?

Annual household Income in US Dollars?

I agree to help preserve Pristine Paradise Palau by respecting all laws, artifacts, and living things while I am here. I will help save natural resources, and the environment to benefit the people of Palau, and future visitors. As such, I promise to conserve islands and beaches, and I will avoid contact with flora and fauna, reefs, corals, marine life, and relics. I will take my trash with me. I will leave the Pristine Paradise Palau as beautiful as I found it as required by law.

Do you have any of the following symptoms, or have you, in the past 14 days?

FEVER*

YES
NO

COUGH*

YES
NO

DIFFICULTY BREATHING OR SHORTNESS OF BREATH*

YES
NO

OTHER SYMPTOMS (SORE THROAT, MUSCLE OR BODY ACHES, NEW LOSS OF TASTE OR SMELL, CONGESTION OR RUNNY NOSE, NAUSEA OR VOMITING, OR DIARRHEA*

YES
NO

If you have any of these symptoms, and have a travel history of visiting areas with wide-spread transmission of COVID-19, please call the Emergency Room (ER) of the Belau National Hospital at (tel): 488-2558

Please list ALL THE COUNTRIES AND CITIES you have visited in the last 14 Days*

If visiting, date of departure from PALAU (Day / Month / Year):*

Have you come into contact with someone confirmed or suspected of having COVID-19 in the last 14 days?*

Yes
Unsure
No

Have you visited a healthcare facility in areas with widespread transmission of COVID-19 in the last 14 days?*

Yes
No

Phone contact in PALAU:*

Name of Local Contact in PALAU:*

Address/Hotel in PALAU:*

DECLARATION: I declare that the details I have given are true and correct and complete in every respect.

Please upload your photo*

Date*

Signature*

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