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‫ﺳـﻔـﺎﺭﺓ ﺍﻟﺠـﺰﺍﺋـﺮ ﺑﺎﻟـﺮﻳـﺎﺽ‬ ‫ﺍﻟــﺠﻤــﻬــﻮﺭﻳــﺔ ﺍﻟــﺠــﺰﺍﺋــﺮﻳــﺔ ﺍﻟــﺪﻳــﻤــﻘــﺮﺍﻃـﻴـﺔ ﺍﻟــﺸـﻌـﺒـﻴـﺔ‬
EMBASSY OF ALGERIA - RIYADH DEMOCRATIC PEOPLE'S REPUBLIC OF ALGERIA
‫ﻃـــــﻠـــــﺐ ﺗـــﺄﺷــــﻴـــــﺮﺓ‬ ‫ﻧﻮﻉ ﺍﻟﺘﺄﺷﻴﺮﺓ‬
Visa type
VISA APPLICATION ................

‫ﺍﻟﻠﻘﺐ‬ ‫ﺍﻻﺳﻢ‬
Family name First name
‫ﺍﻻﺳﻢ ﻗﺒﻞ ﺍﻟﺰﻭﺍﺝ‬ ‫ﺍﻻﺳﻢ ﺍﻵﺧﺮ‬
Malden name Other name PHOTO
‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ‬ ‫ﻓﻲ‬ ‫ﺍﻟﺒﻠﺪ‬
Date of birth At Country ‫ﺍﻟﺮﺟﺎء‬
‫ﺍﺑﻦ‬ ‫ﻭﺍﺑﻦ‬ ‫ﺇﻟﺼﺎﻕ‬
Father's name Mother's name ‫ﺍﻟﺼﻮﺭﺓ ﻫﻨﺎ‬
‫ﺍﻟﺤﺎﻟﺔ ﺍﻟﻌﺎﺋﻠﻴﺔ‬ ‫ﻋﺰﺑﺎء‬/‫ﺃﻋﺰﺏ‬ ‫ﺓ‬/‫ﻣﺘﺰﻭﺝ‬ ‫ﺓ‬/‫ﻣﻄﻠﻖ‬ ‫ﺓ‬/‫ﺃﺭﻣﻞ‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ﺫ‬ ‫ﺃ‬
Marital status(*) Single Married Divorced Widow/er Gender M F
‫ﺍﻟﺠﻨﺴﻴﺔ ﺍﻟﺤﺎﻟﻴﺔ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ﺍﻷﺻﻠﻴﺔ‬
Present Nationality Nationality of birth
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﺸﺨﺼﻲ‬ ‫ ﺑﺎﻹﺩﺍﺭﺓ‬y‫ﺧﺎﺹ‬
Personal address For office use
onl

Husband - wife ‫ﺍﻟﺰﻭﺝ‬

‫ﺍﻟﻠﻔﺐ‬ ‫ﺍﻻﺳﻢ‬ ‫ﺭﻗﻢ ﺍﻟﻄﻠﺐ‬
Family name First name Application number
‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬ ‫ﺍﻟﺒﻠﺪ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
Date of birth Country Nationality
Children ‫ﺍﻷﻃﻔﺎﻝ‬ To be filled only if they travel with you ‫ﻻ ﻳﻤﻸ ﺇﻻ ﻓﻲ ﺣﺎﻟﺔ ﺳﻔﺮ ﺍﻷﻭﻻﺩ‬
‫ﺍﻻﺳﻢ ﻭﺍﻟﻠﻘﺐ‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬ ‫ﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬ ‫ﺗﺎﺭﻳﺦ ﺍﻹﻳﺪﺍﻉ‬
Family name- First name Date of birth Place of birth Nationality Received on

‫ﻋﺪﺩ ﻣﺮﺍﺕ ﺍﻟﺪﺧﻮﻝ‬

‫ﺍﻟﻤﺮﺧﺼﺔ‬
Number of
authorized entries

Type of travel document ‫ﻃﺒﻴﻌﺔ ﻭﺛﻴﻘﺔ ﺍﻟﺴﻔﺮ‬

‫ﺟﻮﺍﺯ ﺳﻔﺮ ﻋﺎﺩﻱ‬ (‫ﻭﺛﻴﻘﺔ ﺃﺧﺮﻯ) ﺗﻮﺿﻴﺢ‬
Ordinary Passport Other document (give precision)
‫ﺭﻗﻢ‬ ‫ﺍﻟﺼﺎﺩﺭ ﺑﺘﺎﺭﻳﺦ‬ ‫ﻳﻨﺘﻬﻲ ﻓﻲ‬
Passport number Issued on Expire on ‫ﻣﺪﺓ ﺍﻹﻗﺎﻣﺔ‬
Duration of stay
‫ﺍﻟﺼﺎﺩﺭ ﻓﻲ‬
Authority
(*)‫ﺗﺄﺷﻴﺮﺓ ﻣﻄﻠﻮﺑﺔ ﻟﻠﺪﺧﻮﻝ‬ ‫ﻣﺮﺓ ﻭﺍﺣﺪﺓ‬ ‫ﻣﺮﺗﻴﻦ‬ ‫ﻋﺪﺓ ﻣﺮﺍﺕ‬ ‫ﻣﻦ‬ ‫ﺇﻟﻰ‬
From To ‫ﺍﻟﻀﺮﻳﺒﺔ ﺍﻟﻤﺴﺘﺤﻘﺔ‬
Visa solicited. for (*) 1 entry 2 entries several entries
Tax
‫ﺍﻟﻤﻬﻨﺔ‬ ‫ﺍﻟﻤﺴﺘﺨﺪﻡ‬
Occupation Employer
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻤﻬﻨﻲ‬ ‫ﺗﺎﺭﻳﺦ ﺻﺪﻭﺭ ﺍﻟﺘﺄﺷﻴﺮﺓ‬
Issued on
Company address

‫ﻓﻲ ﺣﺎﻟﺔ ﻋﺒﻮﺭ‬ ‫ﺍﻟﻮﺟﻬﺔ ﺍﻟﻨﻬﺎﺋﻴﺔ‬

In case of transit What's final destination
(*) ‫ﻫﻞ ﻟﺪﻳﻜﻢ ﺗﺄﺷﻴﺮﺓ ﻟﺪﺧﻮﻝ ﻫﺬﺍ ﺍﻟﺒﻠﺪ‬ ‫ﻧﻌﻢ‬ ‫ﻻ‬
Do you have a visa for this country? (*) Yes ‫ﺍﻟﺘﺎﺭﻳﺦ ﺍﻟﻤﺤﺪﺩ ﻟﻼﺳﺘﻌﻤﺎﻝ‬
No
Exriry date by
‫ﺍﻟﻌﻨﻮﺍﻥ ﺃﺛﻨﺎء ﺍﻹﻗﺎﻣﺔ‬
Address during
your stay
‫ﺍﻟﻐﺮﺽ ﻣﻦ ﺍﻹﻗﺎﻣﺔ‬
Purpose of stay
(*) ‫ﻣﺪﺓ ﺍﻹﻗﺎﻣﺔ‬
30 ‫ﻳﻮﻡ‬ 90 ‫ﻳﻮﻡ‬ ‫ﺁﺧﺮ‬
Length of stay 30 days 90 days other ‫ﺭﺋﻴﺲ ﺍﻟﻤﺮﻛﺰ‬
(*)‫ﻫﻞ ﺳﺒﻖ ﻟﻜﻢ ﺍﻹﻗﺎﻣﺔ ﺑﺎﻟﺠﺰﺍﺋﺮ‬ (‫)ﺍﻹﻣﻀﺎء ﻭﺍﻟﺨﺘﻢ‬
‫ﻧﻌﻢ‬ ‫ﻻ‬
Head of the
Have you been already to Algeria? Yes No post
‫ﻛﻢ‬ ‫ﻓﻲ ﺃﻱ ﺗﺎﺭﻳﺦ‬ ‫ﻣﺪﺓ ﺍﻹﻗﺎﻣﺔ‬ (signature and
How many times? when? length of stay stamp)
e.
‫ ﺍﻟﺠﻮﺍﻝ‬/ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
Tel / Mobile

‫ ﻭﺑﻌﺪﻡ ﺇﻗﺎﻣﺘﻲ ﺑﺼﻔﺔ ﻧﻬﺎﺋﻴﺔ‬،‫ﺃﻟﺘﺰﻡ ﺑﻤﻐﺎﺩﺭﺓ ﺍﻹﻗﻠﻴﻢ ﺑﻌﺪ ﺍﻧﻘﻀﺎء ﺃﺟﻞ ﺍﻟﺘﺄﺷﻴﺮﺓ ﺍﻟﺘﻲ ﺳﺘﻤﻨﺢ ﻟﻲ ﻭﺑﻌﺪﻡ ﻗﺒﻮﻝ ﺃﻱ ﺃﻱ ﻋﻤﻞ ﻣﺄﺟﻮﺭ ﺃﻭ ﻏﻴﺮ ﻣﺎﺟﻮﺭ ﺧﻼﻝ ﺇﻗﺎﻣﺘﻲ‬
I undertake to leave the Algerian territory at the expiration of the visa, and to refuse any employment being paid or not, during my stay,
and do not establish ther
‫ ﻓﻲ ﺣﺎﻟﺔ ﺍﻟﺨﻄﺄ ﺃﻭ ﻋﺪﻡ ﻣﻸ ﺑﻌﺾ ﺍﻟﺨﺎﻧﺎﺕ ﻻ ﻳﺘﻢ ﺍﻟﺮﺩ ﻋﻠﻰ ﻃﻠﺒﻜﻢ‬،‫ ﺗﻤﻸ ﺟﻤﻴﻊ ﺍﻟﺨﺎﻧﺎﺕ ﺑﺤﺮﻭﻑ ﻭﺍﺿﺤﺔ‬:‫ﻫﺎﻡ‬
IMPORTANT: All categories must be completed in CAPITAL LETTERS
In case of mistake or omission, you demand will be rejected. ‫)*( ﺿﻊ ﺍﻟﻌﻼﻣﺔ * ﻓﻲ ﺍﻟﺠﻮﺍﺏ ﺍﻟﻤﺨﺘﺎﺭ‬
(*) Put the Cross in the category corresponding to your answer. (‫ﺗﺎﺭﻳﺦ ﻭﺇﻣﻀﺎء ﺍﻟﻤﻌﻨﻲ ﺑﺎﻷﻣﺮ )ﺻﺎﺣﺐ ﺍﻟﻄﻠﺐ‬
DATE AND APPLICANTS SIGNATURE

MAE-AC-42