FOROFFICIALUSEONLY

R E P U B L ICOF N A MIB IA Approved/ Not Approved

M I N I S T R YOF H OME A F F A IRS
D E P A R T ME N TOF C IV ICA F F AIRS Single/ MultipleEntry
I M M I G R AT IONC ON T R OLA C T , 1993
FileNo.:
APPLICATIONFOR VISA
(section12 and 13/ Regulation11) Dateof issue:..........
1. S ur n ame : Dateof expiry:
2. FirstNames:
3. MaidenName(if applicantis or was a marriedwoman):
Remarks:
ITEMS4 TO 1OTO BE COMPLETED
BY INSERTING
AN'X'IN THE
APPROPRIATE
BOX
4. sex: t Mate -Tl
F"'deTl
5. Marital
- il6d' MtrieJl---lFa,rbdT--]FMor.cedTltrido-M/uo^,erT-l
lNe,/er
6. Haveyou at any time appliedfor a permitto settle
permanentlyin Namibia? FT--] IMTI
7. Haveyoueverbeenrestricted
or refused
entryintoNamibia? Signature:
|Yesf-l fMTl
8. Haveyou ever beendeportedor ordered
to leaveNamibia? lYesTl fMTl Date:...........
9. Haveyoueverbeenconvicted
of anycrimein anycountry? trdT=] trTl
10.Are you suffering fromtuberculosis, or anyothercontagious lungdisease;trachoma, or anyotherchroniceye infection,
frambesia, yaws,scabiesor any othercontagious bacterialor otherskindisease;syphilisor any othervenerealdisease;
or leprosy'cirac(ulreo immuneietiCiencysyfioromviiustlios viru!1,6i anv meniat'iitness or afitiction? |Yesf-l l-M]_l
11. lf the replyto any of the questions6 to 9 is in the atfirmative,attachfull particulars.

13.Citizenship: (lf acquiredby naturalization,

stateoriginalcitizenship.)

(e) ls passportvalidfor travelto Namibia? trdT*l [GTl

16.Addressand periodof residence

in countryof whichyou area permanent
resident:

(b)Willyoube in possession
of anonward/ returnticket? |YesT-l fMTl
(N.8.Separab
applications
havetobecompletedsinrespect
of)ourspouse overtheageof 16year andchildren
orchildren withtheirownpassporb.)
travelling
 NOTE:COMPLETEONLYPARTA OR B
(A) HOLTDAY / WORK/ TRANSITVISA
/ BUSTNESS
1.
2.

lf the purposeof your visit is for medicaltreatment,pleaseprovidethe followinginformation:

Tel.No.:
6. Namesand addressol relativesin Namibia:
NAME NUMBER
ADDRESSANDTELEPHONE RELATIONSHIP

assured,e.g.do you holda visaor a permittor permanent

(d) ls yourentryto thatdestination (proofto be submitted)
residence?
or temporary

(b) RETURN
V|SA
IMPORTANT
An applicanthasto:
(i) producehis or her passportor traveldocument;
and
in Namibiaif notendorsedin hisor herpassport.
(ii) submitproofof his or her rightot residence

of residencein Namibia:
2. Particulars
DATEOF FIRSTENTRY PORTOF ENTRY P E R IOD SOF R E S ID E N C EIN N A MIB IA
From To

to whichyou willbe travelling:

Countries

4.

I solemnlydeclarethat the aboveparticularsgivenby me are true in substanceand in fact and that lfully understandthe meaningthereof.

Signature:
(N.8.Onlythe signature willbe accepted.)
ol the applicant