ON SCREEN FILLABLE FORM

‫اﻟﺠــــﻤﻬـــﻮرﻳــــــــﺔ اﻟﺠـﺰاﺋـﺮﻳــــــﺔ اﻟﺪﻳـﻤﻘـﺮاﻃﻴــــــﺔ اﻟﺸـــــــــــﻌـﺒﻴــــــﺔ‬

PEOPLE'S DEMOCRATIC REPUBLIC OF ALGERIA
Embassy of Algeria Warsaw
‫ﻧﻮع اﻟﺘﺄﺷﻴﺮة‬
‫ﻃــــــــــﻠــــــﺐ ﺗـــــــﺄﺷــــــــﻴـــــــﺮة‬ Visa type
VISA APPLICATION Please select the visa type ……………………..
‫اﻟﻠﻘﺐ‬ ‫اﻻﺳﻢ‬
Family name …………………………………………………….. Given name ………………………………………………
‫اﻹﺳﻢ ﻗﺒﻞ اﻟﺰواج‬ ‫إﺳﻢ اﺧﺮ‬
Maiden name ………………………………………….. Other name ……………………………………………… Please
‫ﺗﺎرﻳﺦ و ﻣﻜﺎن اﻟﻤﻴﻼد‬ dd / MM / yyyy ‫ﻓﻲ‬ ‫اﻟﺒﻠﺪ‬
Date and place of birth …….. …….. …….. at ………………………... Country ……………………………………… glue your photo
‫إﺑﻦ‬ ‫و إﺑﻦ‬
Father’s name ........................................................................... Mother’s name .............................................................................................
here
(*) ‫اﻟﻮﺿﻌﻴﺔ اﻟﻌﺎﺋﻠﻴﺔ‬ ‫أﻋﺰب‬ ‫ﻣﺘﺰوج‬ ‫ﻣﻄﻠﻖ‬ ‫أرﻣﻞ‬ ‫ذآﺮ اﻟﺠﻨﺲ‬ ‫أﻧﺜﻰ‬
Marital status(*) Single Married Divorced Widow (er) Sex(*) M F
‫اﻟﺠﻨﺴﻴﺔ اﻟﺤﺎﻟﻴﺔ‬ ‫اﻟﺠﻨﺴﻴﺔ اﻷﺻﻠﻴﺔ‬
Nationality ………………………………………… Nationality of birth …………………………………………………….

‫اﻟﻌﻨﻮان اﻟﺸﺨﺼﻲ‬
Tel nr:
Home address ………………………………………………………………………………………………………………………………...

HUSBAND - WIFE (must be filled) ‫اﻟﺰوج‬

‫اﻟﻠﻘﺐ‬ ‫اﻻﺳﻢ‬ ‫ﺧﺎص ﺑﺎﻹدارة‬
Family name …………………………………………………………………………………. Given name …………………………………………………………………………………………………………… For official use
‫ﺗﺎرﻳﺦ و ﻣﻜﺎن اﻟﻤﻴﻼد‬ dd / MM / yyyy ‫اﻟﺒﻠﺪ‬ ‫اﻟﺠﻨﺴﻴﺔ‬ only
Date and place of birth ……… ……… ……… Country ……………………………………. Nationality …………………………………………

Not to be filled only if they travel with you ‫ﻻ ﻳﻤﻠﺊ إﻻ ﻓﻲ ﺣﺎﻟﺔ ﺳﻔﺮ اﻷوﻻد‬ ‫رﻗﻢ اﻟﻄﻠﺐ‬
Children ‫اﻷﻃﻔﺎل‬ Application Number
‫اﻻﺳﻢ و اﻟﻠﻘﺐ‬ ‫ ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬Dd/mm/yyyy ‫ﻣﻜﺎن اﻟﻤﻴﻼد‬ ‫اﻟﺠﻨﺴﻴﺔ‬
Family name – Given name Date of birth Place of birth Nationality

‫ﺗﺎرﻳﺦ اﻹﻳﺪاع‬
Received on

Type of travel document ‫ﻃﺒﻴﻌﺔ وﺛﻴﻘﺔ اﻟﺴﻔﺮ‬

‫ﺟﻮاز ﺳﻔﺮ ﻋﺎدي‬ (‫وﺛﻴﻘﺔ أﺧﺮى )ﺗﻮﺿﻴﺢ‬ ‫ﻋﺪد ﻣﺮات اﻟﺪﺧﻮل اﻟﻤﺮﺧﺼﺔ‬
Ordinary Passport other document (please be specific)…………………………………………………………………………. Nbr of authorised entries

‫رﻗﻢ‬ ‫اﻟﺼﺎدر‬ ‫ﻳﻨﺘﻬﻲ ﻓﻲ‬ dd / MM / yyyy

number issued on by Expire on ……... ……... ……...
‫ﻣﺪة اﻹﻗﺎﻣﺔ‬
(*) ‫ﺗﺄﺷﻴﺮة ﻣﻄﻠﻮﺑﺔ ﻟﻠﺪﺧﻮل‬ ‫ﻣﺮة واﺣﺪة‬ ‫ﻣﺮﺗﻴﻦ‬ ‫ﻋﺪة ﻣﺮات‬ ‫ﻣﻦ‬ dd/ MM/yyyy ‫اﻟﻰ‬ dd/MM/yyyy Duration of journey
Number of entries (*) 1 entry 2 entries multiple entries from …. …. …. to …. …. ….

‫اﻟﻤﻬﻨﺔ‬ ‫اﻟﻤﺴﺘﺨﺪم‬ ‫اﻟﻀﺮﻳﺒﺔ اﻟﻤﺴﺘﺤﻘﺔ‬

occupation …………………………………………………………... name of the company…………………………………………………… Fees

‫اﻟﻌﻨﻮان اﻟﻤﻬﻨﻲ‬
address of the compagny…………………………………………………………………………………………………………………………………...
‫ﺗﺎرﻳﺦ ﺻﺪور اﻟﺘﺄﺷﻴﺮة‬
Issued on
‫ﻓﻲ ﺣﺎﻟﺔ ﻋﺒﻮر‬ ‫اﻟﻮﺟﻬﺔ اﻟﻨﻬﺎﺋﻴﺔ‬
IN CASE OF TRANSIT : Final destination ……………………………………………………………….............................……………………
(*) ‫هﻞ ﻟﺪﻳﻜﻢ ﺗﺄﺷﻴﺮة دﺧﻮل ﻟﻬﺬا اﻟﺒﻠﺪ‬ ‫ﻧﻌﻢ‬ ‫ﻻ‬
Do you have a visa for this country (*) yes no ‫اﻟﺘﺎرﻳﺦ اﻟﻤﺤﺪد ﻟﻼﺳﺘﻌﻤﺎل‬
‫اﻟﻌﻨﻮان أﺛﻨﺎء اﻹﻗﺎﻣﺔ‬ Expiry date :
Adress during your journey…………………………………………………………………………………………………………………………………...
‫ﻏﺮض اﻹﻗﺎﻣﺔ‬
Purpose of journey………………………….………………………………………………………………………………………………………………... ‫رﺋﻴﺲ اﻟﻤﺮآﺰ‬
‫ﻣﺪة اﻹﻗﺎﻣﺔ‬ ‫ ﻳﻮم‬30 ‫ ﻳﻮم‬90 Others (be specific) ‫اﺧـــﺮ‬ (‫)اﻹﻣﻀﺎء و اﻟﺨﺘﻢ‬
Officer
Duration of journey 30 days 90 days
(Signature and stamp)
‫هﻞ ﺳﺒﻖ ﻟﻜﻢ اﻹﻗﺎﻣﺔ ﺑﺎﻟﺠﺰاﺋﺮ‬ ‫ﻧﻌﻢ‬ ‫ﻻ‬
Have you been to Algeria before? yes no

‫آﻢ‬ ‫ﻓﻲ أي ﺗﺎرﻳﺦ‬ ‫ﻣﺪة اﻹﻗﺎﻣﺔ‬

how many times?………… When ? ………………………………Duration of stay…………………………………………………….

‫و ﺑﻌﺪم اﻹﻗﺎﻣﺔ ﺑﺼﻔﺔ ﻋﻔﺎﺋﻴﺔ‬،‫أﻟﺘﺰم ﺑﻤﻐﺎدرة اﻹﻗﻠﻴﻢ ﺑﻌﺪ اﻧﻘﻀﺎء أﺟﻞ اﻟﺘﺄﺷﻴﺮة اﻟﺘﻲ ﺳﺘﻤﻨﺢ ﻟﻲ و ﺑﻌﺪم ﻗﺒﻮل أي ﻋﻤﻞ ﻣﺄﺟﻮر أو ﻏﻴﺮ ﻣﺄﺟﻮر ﺧﻼل إﻗﺎﻣﺘﻲ‬
I undertake to leave the Algerian territory at the expiration of the visa which would be granted to me, and to refuse any employment being paid or not, during my
journey and to not establish me there
‫ ﻓﻲ ﺣﺎﻟﺔ ﺧﻄﺊ أو ﻋﺪم ﻣﻠﺊ ﺑﻌﺾ اﻟﺨﺎﻧﺎت ﻟﻦ ﻳﺮد ﻋﻦ ﻃﻠﺒﻜﻢ‬،‫هﺎم ﺗﻤﻠﺊ ﺟﻤﻴﻊ اﻟﺨﺎﻧﺎت ﺑﺤﺮوف واﺿﺤﺔ‬
IMPORTANT :Please print in block letters. INCORRECT INFORMATION WILL RESULT IN
REFUSAL OF VISA APPLICATION.
(*) put the Cross in the categoty ‫)*(ﺿﻊ ﻋﻼﻣﺔ × ﻓﻲ اﻟﺠﻮاب اﻟﻤﺨﺘﺎر‬
corresponding to your answer.
(‫ و أﻣﻀـﺎء اﻟﻤﻌﻨﻲ)ﺻــﺎﺣﺐ اﻟﻄـﻠﺐ‬،‫اﻟﺘﺎرﻳﺦ‬
DATE AND APPLICANT'S SIGNATURE
MAE – AC 42 .