3-1/0033

REPUBLIC OF NAMIBIAMinistry of Home Affairs and Immigration

Immigration Control Act, 1993

APPUCATION FOR VIS A(Sections 12 and 13 / Regulation 11)

hems 4to 10 to be completed by inserting an "X". in the appropriate box.

1. Surname:

2. First name*:.

3. Maiden name (if applicant is or was a married woman):

PSkNoj.

FOR OFFICIAL USE ONLYApproved / Not Approved

Single/Multiple entry

Pate of issue:.

Date of expiry:.

Remarks:

Signature:.

Date:

4. S«x: Male P«n.V 5. Marital status: Never Married

6. Haveyoaatanytir«apDlicdforaDOTnittosettleperinanenliyinNaniibia?

7. Have you ever been restricted or refused entry to Namibia?

8. Have you ever been deported or ordered to kave Namibia?

9. Have you ever been convicted of any crime fin any country?

Married

Yesl 1

%sl

Yes

Yes

[NONo

irDivorced Widow/Widower

=

Nol

ran f

11 .If me reply to any one of mequestions 6to 10 ism me affirmative, attach fnD particulars.

12. Birm (a) Date: (b) Place: , _

13. Citizenship: _:

14. Passport (a) Number:

(c) Date of issue: '.

Country.

(D) Place of issue.

(d) Date of expiry:.

(e) Is passport valid for travel to Namibia:

IS. (a) Present residential i

16. Address and period of residence in country of which you are a]

(a) Residential address: ,

Cb) Telephone no.: ( )

17.'Occupation or Profession: -

_(b) Telephone no.: (.t resident:

.(c) Period:.

18. Firm, cainpany.uinversny, etc,, to wrrich you are attach

(a) Name and address of employer: ^

(b) Telephone no.: (_ ) , .

(c) Nature of business: ' ;

<d) If a student, name of university to which you are attached and the coarse pi

19. S accompanied by your wife and children state:

First Names

to

0>)

<c)

DateofBirta Place of Birth

20. (a) What amount of money wul you have available on arrival in Namibia for your own use? VN$.

(b)Wm yon be m possession of an ~a^a^K a f 1C V^aW a

NOTE: COMPLETE ONLY PART AOR B(A)HOUDAY/BGSINESS/WORK/TRANSn/VISA

1. Intended date and port of arrival m Namibia: ; :_2. (a) What is me purpose of you visit?

(b) If it is for business purposes, explain in detail me nature of business:.

(c) Duration of intended visit (Number of days, weeks or months).

3. Places tobe visited m NanriWa (fM address, nxtotag tekphoo^

4. If me purpose of yoar visit is for medical treatment, please provide the fottoying information:

(a) Name of doctor, hospital or dink you wffl visit: _

(b) Who will pay your medical expenses and hospital fees:.<c)If you are liable for the expenses and fees above, state amount of ftmds available:.

5. Proposed residential address in Namibia:

6. Names and addresses of relatives in Namibia:JIekpjlioneno.:(_

Nam*

Ca)

0>) '

AddRHaodtTUcvboawBinuber fTfffrt^^irfr

7. Date of last visit, if any, to Namibia: ,

8. Do yon conttibnte professionally w

9. (a) Destination after leaving Namibia:

{b) Mode of travel to destination: • -(c) blended dale and poet of departure:

(d)Isyowen»rytoliiatdestinationass

10. Reasons for travelling through Namibia:

(B)SETUBNVEA r :

IMPCHTCANT -An applicant has to:© produce his or her passport or travel document; and

m^

1. (a) Kindof Petnnt andntonber..

(b) Date of t

(c) Expected date of return:.2. Partfcolara of Residence in Namibia:

IMeoTflnt cater Port of cattyTtia^ n ttm -m •*-— -- l a ^UAi nNMBs 01 naaoncB • m am

v9m • ' • n knom 10

3. Couotries to which you wfll be travelling:

(a) : (b).

4. Puposeof journey (explain fuBy):

^ I scdenmtydedace that tte above particulars

Date: , •.

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