1625 K Street NW Suite 750 Washington DC 20006 Tel: 888 838 … · 2014. 6. 30. · PLEASE BE CERTAIN TO RETURN THE FOLLOWING TO: Pinnacle Travel Document Systems. 1625 K Street NW

1625 K Street NW Suite 750 Washington DC 20006 Tel: 888 838 4867 ♦ Email: [email protected]

Visa requirements shown below are for U.S. citizens ONLY. Nationals of all other countries please contact

Pinnacle Travel Document Systems directly for specific requirements for your itinerary.

Cambodia 1 1 Laos 1 1 Myanmar 3 3

Please enclose your actual passport along with five (5) photographs, one (1) completed visa application form each for Cambodia and Laos and two (2) completed visa application forms and one (1) completed Work History form for Myanmar. Please also enclose two (2) clear photocopies of the vital information page of your passport, a copy of your flight itinerary showing entry and exit for Myanmar and your internal travel itinerary obtained from Alexander+Roberts. Photographs should be passport-type with a clear background approximately 2” x 2” in dimension. (Note that machine or home digital photographs are not acceptable and must be different than those in your current passport.) Your passport must be valid for a minimum of six (6) months beyond the completion of your travel and must have at least six (6) blank unused pages available not including those reserved for amendments and endorsements at the back of your passport. Contact PTDS directly for assistance with renewal of or to add pages to your U.S. passport, as this can easily be done at the same time you apply for your visa.

Fees shown above include all necessary consular and service fees as well as the cost to return your passport(s) from our offices via FedEx within the continental U.S. (Please add $29.00 to cover extra shipping costs for addresses in Alaska, Hawaii, or Canada.) We strongly suggest that you send your documents to us via FedEx or some other form of traceable overnight courier service.

Visa(s) # # Cost Req’d Forms Photos 1 – Persons - 2

Application Expedite Fee Deadline Per Person

60 days prior $130.00 to your departure

Adventures in Thailand, Laos & Angkor Wat

Extension

Applications must be received in our offices no fewer than 60 days prior to your departure from your shipping address. Documents received after the deadline will be subject to the per person late fee shown above. (Please do not submit your documents more than 90 days before your departure due to the validity of your visas.) Special requests for passports to be expedited due to other travel plans prior to your tour departure may also require expediting fees. Please contact PTDS directly regarding any special processing needs or before submitting documents you expect may be received substantially after the deadline as there may be special requirements and/or additional fees to process your request. It may not be possible to cancel processing of your applications once they have been submitted.

Please note that consular fees, shipping fees and application requirements quoted are subject to change without notice. Check or credit card payment accepted. Credit card payment subject to 3.5% surcharge.

$289.00 $549.00

If you prefer to obtain your visas for Cambodia and Laos on arrival deduct $260.00 from the fees shown above. Visas for Myanmar MUST be obtained prior to departure. Visas are not required for short tourist stays in Thailand. Due to short

validity of the Lao visa please note that your passport may not be returned until approximately 30 days prior to your departure. Given persistent delays with processing your visa for Myanmar may not be obtainable if documents are received

after the deadline. Please use the enclosed sample information verbatim and substitute your personal information.

mailto:[email protected]

PLEASE BE CERTAIN TO RETURN THE FOLLOWING TO: Pinnacle Travel Document Systems

1625 K Street NW Suite 750 Washington DC 20006

♦ Your actual passport (Please keep a photocopy for your records.) ♦ This completed form ♦ Two (2) clear photocopies of the vital information page of passport ♦ One (1) completed visa application form per person for Cambodia ♦ One (1) completed visa application form per person for Laos ♦ Two (2) completed visa application forms per person for Myanmar ♦ One (1) completed Work History form per person for Myanmar ♦ One (1) copy of your flight itinerary showing entry and exit for Myanmar ♦ One (1) copy of your internal travel itinerary obtained from Alexander + Roberts ♦ Five (5) passport-type photographs per person

♦ Credit or debit card authorization below

PLEASE TYPE OR PRINT CLEARLY

Full Name:________________________________ Full Name:________________________________

Passport #:____________________ Exp:___/___ Passport #:____________________ Exp:___/___ Mo Y r Mo Y r

Home ________________________________ Home Tel: ________________________________

Mailing ________________________________ Work Tel: ________________________________

Address: ________________________________ Email: ____________________________________

________________________________ Date of Departure from Home: ____/____/_____ (FedEx cannot deliver to PO boxes) Mo nt h Da y Ye a r

Address ________________________________ Tour Name: Thailand, Laos & Angkor Wat

For Return________________________________ Date of Tour Departure: ____/____/_____ Mo nt h Da y Ye a r Of ________________________________ Date of Entry to Laos: _____________________

Passport: ________________________________ Special Instructions:___________________

Tel: ________________________________ _________________________________________

Please indicate below if there are known periods prior to your tour during which you will need your passport for another international tr ip or when you will not be available to sign for the return of your passport. I wil l need my passport(s) for other international travel from _____/____/_____ to _____/____/_____ Mo nt h Da y Yea r Mo nt h Da y Yea r

I wil l not be at my home and/or return shipping address from _____/____/_____ to _____/____/_____ Mo nt h Da y Yea r Mo nt h Da y Yea r

CREDIT CARD AUTHORIZATION: AMEX / V ISA / MC (please circle one)

Cardholder Name:_____________________ Signature:______________________ Bi l l ing Zip Code: _____________

Card #: ______________________________CID#______________ Expires: ____/___ Amount: US$ _________ Mo Y r A+R CAMB/LAOS 2014(LAOS55/CAMBX65/MYANMAR25)70 394/759 FX29 (APP FEE)10 6PGS VAL 6MOS DL 60DAYS 130.00 3.5% TE LAOS 60 DAYS (SEE ENTRY ABOVE) TE CAMBODIA 90 DAYS

2014 – Pinnacle Travel Document Systems

IMPORTANT NOTICE REGARDING PASSPORT PAGES & VALIDITY:

You must have at least six (6) blank unused pages available in your passport for visas and entry/exit stamps, not including those at the back of your passport reserved for amendments and endorsements to the passport. In addition, your passport must be valid for six (6) months beyond the completion of your travel. If you are a U.S. citizen, and need to renew or add pages to your passport Pinnacle Travel Document Systems can easily assist you with this at the same time your visas are being processed. The total additional fees for these services (including U.S. government expediting fees) are $222.00 for passport pages and $250.00 for passport renewals.

You will need to complete an application form and a letter of authorization for PTDS and must send your actual passport to us. Specific requirements and the necessary forms are available for download from our Internet site:

Passport Pages Passport Renewals

First Time Passports Second Passports

WWW.Traveldocs.com/PTDSPassports

You may also contact us via email at [email protected] or by phone at 888-838-4867 and we will send you an instruction kit.

mailto:[email protected]

DIRECTORATE OF IMMIGRATION AND NATIONAL REGISTRATION IMMIGRATION DEPARTMENT

APPLICATION FOR TOURIST ENTRY VISA

(To be handed over to the immigration officer at the airport.) 1. Name ......................................................... PHOTO 2. Father’s Name in Full .................................................... 3. Nationality ......................... 4. Sex .................................. 5. Date of Birth ............................... 6. Place of Birth ........................ 7. Occupation .............................................................................................................. 8. Personal description

(a) Colour of Hair ......................... (b) Height .................................................. (c) Colour of eyes ........................ (d) Complexion ..........................................

9. Passport (a) Number ................................ (b) Date of Issue .......................................... (c) Place of Issue ...................... (d) Issuing Authority ..................................... (e) Date of Expiry ..............................................................................................

10. Permanent Address ................................................................................................ 11. Address in Myanmar ............................................................................................... 12. Purpose of entry into Myanmar ............................................................................... 13. Name and address of guarantor during stay in Myanmar .......................................

................................................................................................................................. 14. Financial resources in Myanmar ............................................................................. (a) Cash (Kyats and Foreign Currency) .................................................................. (b) Bank deposit ...................................................................................................... (c) Name of Bank .................................................................................................... (d) Amount .............................................................................................................. 15. Attention for Applicants

(a) Apart from the professions mentioned in this visa application are not to engage in any sort of work with or without changes.

(b) Applicant shall abide by the laws of the Union of Myanmar and shall not interfere in the internal affairs of the Union of Myanmar.

(c) Legal action will be taken against those who violate or contravene any provision of the existing laws, rules and regulations of the Union of Myanmar.

I hereby declare that I fully understand the above mentioned conditions that the particulars given above are true and correct and that I will not engage in any activities irrelevant to the purpose of entry stated herein.

16. Daytime phone no. .................................................. ..................................

Date .............................. Signature of applicant .......................................................................................................................................

(FOR OFFICIAL USE ONLY) Visa No. .......................................... Date ................................. Visa Authority ............................................................................

Date ............................ Signature of Office-in-charge Place ........................... Consulate General of the Union of Myanmar New York

2

PLEASE DATE AND SIGN YOUR APPLICATIONS

FORM A

JOHNATHAN BONHAM DOEJOHANN SEBASTIAN DOE

USA MALE13 MARCH 1961 USA

ENGINEER

BROWN 5 FT. 11 INCHESBROWN CAUCASION

9876543210 12 JANUARY 2010USA DEPT OF STATE11 JANUARY 2020

1234 MAIN STREET ANYWHERE USA 98765

CHATRIUM HOTEL ROYAL LAKE YANGON MYANMAR

TOURISMDESTINATION ASIA

ROOM 1 2ND FL. PEARL CONDO BUILDING A KABA AYE PAGODA ROAD YANGON MYANMAR

PRE PAID TOURNOT APPLICABLE

NOT APPLICABLENOT APPLICABLE

NOT APPLICABLE

987-654-3210

ROYAL EMBASSY OF CAMBODIA IN : Washington D.C.

KINGDOM OF CAMBODIA Nation Religion King

~ ~

VISA APPLICATION FORM Photograph

4 x 6

Please submit 1 copy with 1 photo and your passportSurname: Present occupation:

First name:

Sex: Male FemaleDate of birth: Day..…..Month………Year…......Place of birth: ……………………………………

Place of residence:

Fax: /Phone:

Birth nationality:Present nationality: Work Place:

Passport of traveling document is valid for (country)

Date of entry to Cambodia: Day.….Month……Year…….Date of departure (length of stay)

Purpose of visit Diplomatic Tourist Official Business Others (Please Specify)

Point of entry:Means of Transportation:

Point of exit: Means of Transportation:

Address during the visit: Organization, Persons to be visited :First trip to Cambodia Yes

No

Passport No:Place of issue:Date of issue:Date of Expiration: Traveling on group tour Yes

NoSexSurname First name

Patronymic M FDate of birth Permanent

AddressChildren under 12 years

traveling with you

Relatives in the Kingdom of Cambodia

I hereby declare that the information on this form is true and correct

Place, (Date)………..…………….

(Signature of the applicant)

For official use

éf¶pþl; …………........... Tidæakarelx ………………elxsMKal;………………

RbePT …………………

éf¶ …… Ex …… qñaM ……

htßelxam®nþITTYlbnÞúkkic©karkugs‘ul

PLEASE DO NOT FORGET TO DATE AND SIGN YOUR VISA APPLICATION

PLEASE STAPLE ONE (1) PHOTO HERE

DOE Engineer

Jonathan Bonham✔

1234 Main Street Anywhere CA 98765

987-654-3210 No Fax03 MARCH 1961

USAUSA ABC International, Inc.

ALL COUNTRIESPER YOUR 2014

PER YOUR ITINERARY

✔

SIEM REAP

AirSIEM REAP

AIR

RAFFLES HOTEL, SIEM REAP

RAFFLES HOTEL, SIEM REAP DESTINATION ASIA

0123456789US Department of State

09 MAY 1999 10 MAY 2015

✔

✔

NONE

NONE

Los Angeles CA USA

GENERAL TOURS

PLEASE STAPLE 1 PHOTO HERE

PLEASE DO NOT FORGET TO DATE AND SIGN YOUR VISA APPLICATION

Jonathan DOE

13 MAR 1961 Los Angeles CA USA

USA Engineer

0123456789 National Passport Center

10 MAY 2005 09 MAY 2015

1234 Main Street Anywhere CA 98765 987-654-3210

NOT APPLICABLE

FOR US PASSPORTHOLDERS

TOURISM

PER YOUR ITIN AIR

HUAY XAI PER YOUR ITIN

DESTINATION ASIA 856 71 260 881

HOUSE NO. 04 UNIT 1 BAN KHILI LUANG PRABANG LAOS

SIEM REAP, CAMBODIA

GENERAL TOURS

Visa is valid for 3-months from the date of issue Copy No.1

EMBASSY OF THE REPUBLIC OF THE UNION OF MYANMAR, WASHINGTON D.C. APPLICATION FOR ENTRY VISA (TOURIST)

1. Name in Full ( Fill in Block Letters)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

( First Name ) (Middle Name ) ( Last Name)

2. Father's Full Name _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _


3. Date of Birth (dd/mm/yyyy): _ _ / _ _ / _ _ _ _

4. Place of Birth (City / State / Country): _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _

5. Nationality: U.S. / (Others): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. Sex (F) / (M)

6. Present Occupation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(If retired write " retired", if student write "student")

7. Marital Status: Married Separated Divorced Widowed Single (Never Married)

8. Spouse's Full Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Personal Description

9. (a) Color of Hair _ _ _ _ _ _ _ _ _ _ _ (b) Height: m _ cm _ _ / ft. _ in. _ _

(c) Color of Eyes _ _ _ _ __ _ _ _ _ _ (d) Complexion _ _ _ _ _ _ _ _ _ _ _ _ _ _

Passport 10. (a) Number _ _ _ _ _ _ _ _ _ _ _ _ (b) Date of Issue (dd/mm/yyyy) _ _ / _ _ / _ _ _ _

(c) Dt. of expiration (dd/mm/yyyy): _ _ / _ _ / _ _ _ _

(d) Place of issue: (e) Issuing Authority:

United States, _ _ _ _ _ _ _ _ _ _ _ United States, Department of State / Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ National Passport Centre / Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

11. Present Address in U.S. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Include apartment number, street, city, state or province & postal zone)

12. Contact Phn. No. (Res.) ( _ _ _ ) _ _ _ _ _ _ _ (Work) ( _ _ _ ) _ _ _ _ _ _ _ e-mail:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

13. Address in Myanmar:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

14. Have you ever been to Myanmar: Yes No (If Yes) Date of Last Visit: (dd/mm/yyyy): _ _ / _ _ / _ _ _ _

15. Have you ever been refused to enter Myanmar: Yes No. (If Yes) When: (dd/mm/yyyy): _ _ / _ _ / _ _ _

Why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

16. Purpose of Visit: Tourism / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(Expected date of Arrival: _ _ / _ _ / _ _ _ _ Flight No._ _ _ _ _ _ & Departure: _ _ / _ _ / _ _ _ _ , Flight No. _ _ _ _ _ ) dd mm yyyyy dd mm yyyyy

Attention for Applicant: (a) Apart from the professions mentioned this visa application form applicants are not to engage in any sort of work, with or without charges.

(b) Applicant shall abide by the Laws of the Republic of the Union of Myanmar and shall not interfere in the Internal Affairs of the Republic of the Union of Myanmar. (c) Legal action will be taken against those who violate or contravene any provision of the existing laws, rules and regulations of the Republic of the Union of Myanmar. I hereby declare that I fully understand the above mentioned conditions, that the particulars given above are true and correct and that I will not engage in any activities irrelevant to the purpose of entry stated herein.

-------------------------------------------- Signature of Applicant

Date (dd/mm/yyyy) : _ _ / _ _ / _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (FOR OFFICE USE ONLY)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Visa No. ___________________ Date : ________________________ Visa Authority:MOFA Lt. No. 46 11 11 (76) Dated : 11 March 1994 (If other): MOFA Lt. No. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, Dated:_ _ _ _ _ _ _

Signature of Officer in-Charge

Embassy of the Republic of the Union of Myanmar WashingtonD.C., U.S.A Contact : Tel. (202) 332 4352, (202) 238 9332 Fax.(202) 332 4351. http://mewashingtondc.com , e-mail: [email protected]) Up Dated : May, 2014

PHOTO Recently taken

color photo

with full face, front view, no hat

and against a plain light background

Official use only E.V.T(F.I.T) E.V.T (Package Tour)

DO NOT FORGET TO SIGN AND DATE YOUR APPLICATIONS

JOHNATHAN BONHAM DOE

JOHANN SEBASTIAN BACH

13 03 1961

LOS ANGELES USACALIFORNIA

✔ ✔

ENGINEER

✔

JOANNA DOE

BROWN ✔ 5 11BROWN CAUCASION

9876543210 09 02 201008 02 2020

✔

1234 MAIN ST. ANYWHERE, CALIFORNIA USA

987654-3210 456-1234987 [email protected] HOTEL ROYAL LAKE YANGON, MYANMAR

✔

✔

✔ PRE PAID TOUR WITH ALEXANDER+ROBERTSIP Y PYI P Y I PYI

Embassy of the Republic of the Union of Myanmar Washington D.C.

Work History for Visa Applicant

1. Name in Full (Fill in block letters):___________________________________________

Surname (As in Passport):_________________________________________________

First Name & Middle Name:________________________________________________

2. Date of birth (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

3. Place of birth: U.S., ______________________ (Other): _____________________

4. Permanent Home Address:_________________________________________________

______________________________________________________________________

5. Tel. (Res.) ( ) _____________ (Work Place) ( ) ____________

e-mail: ___________________________________________________

6. Work Description (Current)

Job Title :__________________________________________________________

From(dd/mm/yyyy):____/___/______-To (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

(b) Office __________________________________________________________

Department ________________________________________________________

Describe your Duties: _____________________________________________

_______________________________________________________________

7. Work Description (Previous)

(a) Job Title:____________________________________________

From (dd/mm/yyyy) _ _ / _ _ /_ _ _ _ To (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

(b) Office __________________________________________________________

Department ________________________________________________________


_______________________________________________________________

_______________________________________________________________

I hereby declare that the particulars given above are true and correct and that I will not engage in any

activities irrelevant to the purpose of my entry.

____________________

Signature of Applicant

Date: (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

Up Dated : May, 2014

DO NOT FORGET TO SIGN AND DATE YOUR APPLICATIONS

JOHNATHAN BONHAM DOE

DOEJOHNATHAN BONHAM

13 03 1961

✔ LOS ANGELES, CA1234 MAIN ST. ANYWHERE, CALIFORNIA USA

987 654-3210 987 [email protected]

ENGINEER 09 07 2005 06 25 2014

ENGINEERINGENGINEERING

ENGINEERING

PRODUCTION MANAGER12 10 1990 09 07 2005

PRODUCTIONPRODUCTION

PRODUCTION




_ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
























Why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _










color photo





✔ PRE-PAID TOUR WITH ALEXANDER+ROBERTS




_ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ / _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
























Why: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _










color photo





✔ PREPAID TOUR WITH ALEXANDER+ROBERTS

Embassy of the Republic of the Union of Myanmar Washington D.C.

Work History for Visa Applicant

1. Name in Full (Fill in block letters):___________________________________________

Surname (As in Passport):_________________________________________________

First Name & Middle Name:________________________________________________

2. Date of birth (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

3. Place of birth: U.S., ______________________ (Other): _____________________

4. Permanent Home Address:_________________________________________________

______________________________________________________________________

5. Tel. (Res.) ( ) _____________ (Work Place) ( ) ____________

e-mail: ___________________________________________________

6. Work Description (Current)

Job Title :__________________________________________________________

From(dd/mm/yyyy):____/___/______-To (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

(b) Office __________________________________________________________

Department ________________________________________________________


_______________________________________________________________

7. Work Description (Previous)

(a) Job Title:____________________________________________

From (dd/mm/yyyy) _ _ / _ _ /_ _ _ _ To (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

(b) Office __________________________________________________________

Department ________________________________________________________


_______________________________________________________________

_______________________________________________________________

I hereby declare that the particulars given above are true and correct and that I will not engage in any

activities irrelevant to the purpose of my entry.

____________________

Signature of Applicant

Date: (dd/mm/yyyy) _ _ / _ _ /_ _ _ _

Up Dated : May, 2014

ROYAL EMBASSY OF CAMBODIA IN : Washington D.C.

KINGDOM OF CAMBODIA Nation Religion King

~ ~

VISA APPLICATION FORM Photograph

4 x 6

Please submit 1 copy with 1 photo and your passportSurname: Present occupation:

First name:

Sex: Male FemaleDate of birth: Day..…..Month………Year…......Place of birth: ……………………………………

Place of residence:

Fax: /Phone:

Birth nationality:Present nationality: Work Place:

Passport of traveling document is valid for (country)

Date of entry to Cambodia: Day.….Month……Year…….Date of departure (length of stay)

Purpose of visit Diplomatic Tourist Official Business Others (Please Specify)

Point of entry:Means of Transportation:

Point of exit: Means of Transportation:

Address during the visit: Organization, Persons to be visited :First trip to Cambodia Yes

No

Passport No:Place of issue:Date of issue:Date of Expiration: Traveling on group tour Yes

NoSexSurname First name

Patronymic M FDate of birth Permanent

AddressChildren under 12 years

traveling with you

Relatives in the Kingdom of Cambodia

I hereby declare that the information on this form is true and correct

Place, (Date)………..…………….

(Signature of the applicant)

For official use

éf¶pþl; …………........... Tidæakarelx ………………elxsMKal;………………

RbePT …………………

éf¶ …… Ex …… qñaM ……

htßelxam®nþITTYlbnÞúkkic©karkugs‘ul

ALL COUNTRIES2014

✔

Siem Reap

AIR

SIEM REAP

AIR

RAFFLES GRAND HOTEL D'ANGKOR

RAFFLES GRAND HOTEL D'ANGKOR DESTINATION ASIA

✔

GENERAL TOURS

TOURISM

HUAY XAI

DESTINATION ASIA 856 71 260 881

HOUSE NO 04 UNIT 1 BAN KHILI LUANG PRABANG LAOS

SIEM REAP, CAMBODIA

GENERAL TOURS