TO BE SUBMITTED APPROXIMATELY

30 DAYS BEFORE DEPARTURE

REPUBLIC OF SOUTH AFRICA For Official Use Only

VISA APPLICATION
BLOCK LETTERS ONLY NO. ___________________________________________

N.B. ALL QUESTIONS TO BE ANSWERED FULLY. TYPE OF

FAILURE TO DO SO MAY RESULT IN A POSSIBLE DELAY. VISA ___________________________________________

1. Last Name __________________________________________________________ DATE OF

EXPIRY _______________________________________
2. First names __________________________________________________________

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

REMARKS ______________________________________
__________________________________________________________________
ITEMS 4 TO 10 TO BE COMPLETED BY INSERTING AN X ________________________________________________
IN THE APPROPRIATE SQUARE
Male Female ________________________________________________
4. Sex

5. Marital Status Widow/

Single Married Divorced Widower ________________________________________________
6. Have you at any time applied for a permit
to settle permanently in South Africa? Yes No DATE OF
ISSUE _________________________________________
7. Have you ever been restricted or refused
entry to South Africa? Yes No

8. Have you ever been deported from or

ordered to leave South Africa? Yes No
To facilitate the return of your passport please enclose a SELF-
9. Have you ever been convicted of any ADDRESSED STAMPED ENVELOPE for certified/ registered mail.
crime in any country? Yes No (METERED POSTAGE NOT ACCEPTED)

10. Are you suffering from tuberculosis,

any other infectious or contagious disease Yes No
or any mental or physical deficiency?
11. Particulars if the reply to one or more of questions 6 to 10 is in the affirmative ______________________________________________________________________

___________________________________________________________________________________________________________________________________

12. Date of Birth __________________________________ Town __________________________________ Country _______________________________________

13. Nationality _______________________________ (if acquired by naturalization state original nationality) _______________________________________________

14. Passport: Number __________________ Place of Issue ____________________ Date of Issue ___________________ Date of Expiry _______________________

15. Home address and period of residence in the country of which you are a permanent resident:

Address ____________________________________________________________________________________________________________________________

Telephone _________________________________________________ Period of residence _______________________________________________________

16. Present address (if different from 15) _____________________________________________________________________________________________________

17. Firm, company, university, etc. to which you are attached or which you represent in the U.S.A.

Name ________________________________________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________________________

Nature of your business or that of your Employer in the U.S.A. (or, in the event of a student, course followed) ______________________________________

___________________________________________________________________________________________________________________________________

18. Occupation and profession or position you hold in above organization (if retired state details of previous occupation) ________________________________
(See Reverse Side)
19. What is the object of your visit to the Republic of South Africa? _______________________________________________________________________________

___________________________________________________________________________________________________________________________________

(If for business or for employment please attach supporting letter from your firm or your prospective employer. Prospective students should attach letter
from school or University).

20. a) Date of departure from the United States? _______________________________________________________________________________________________

b) Date and port of arrival in the Republic of South Africa? ___________________________________________________________________________________

21. Are you a member of an organized tour group? Yes ❑ No ❑ (If “Yes” attach itinerary)

22. Duration of intended visit __________________________________________________________________________________ (number of days, weeks or months)

23. Places to be visited in South Africa (Full address - if for temporary residence or temporary employment, list address at which you will reside or be employed)

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

24. Particulars of children under the age of 16 years entered in your passport and accompanying you: –

(Both Parents or the legal Guardian(s) to sign application form of child under the age of 16 years.)

Last Name and First Names Sex Date of Birth Place of Birth

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

25. Organizations and / or person(s) (including businesses, relatives and acquaintances) you will be contacting or know in South Africa:

Name Address and Telephone Number Nature of Business of Organization (or Relationship)

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

26. Date of last visit, if any, to South Africa ___________________________________________________________________________________________________

27. What amount of money will you have on arrival in South Africa for your own use? ___________________________________________________________________

28. Do you contribute professionally or otherwise (Not including financial contributions) to publications, radio, television or films? Yes ❑ No ❑

If “Yes” please give details _____________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

29. (a) Onward Destination ______________________________________________ (b) Do you hold an onward or return ticket? ____________________________

(c) Is your entry to the above destination assured, e.g., do you hold a visa? _____________________________________________________________________

(b) Intended date of departure from South Africa ___________________________________________________________________________________________

(e) Intended port of departure from South Africa __________________________________________________________________________________________

I SOLEMNLY DECLARE THAT THE ABOVE PARTICULARS GIVEN BY ME ARE TRUE IN SUBSTANCE AND IN FACT AND THAT I FULLY UNDERSTAND THE
MEANING THEREOF.

Signature of Applicant ____________________________________________________________________________ Date ___________________ 19 _________

FOR OFFICIAL USE ONLY

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________