Tier 1 (General) - Main Applicant Questionnaire Country)

Tier 1 (General) – Main applicant questionnaire
Part 2: About you
2.1 Given name(s)

ANDRE
2.2 Family name

LE ROUX
2.3 Other names
2.4 Sex
Male
2.5 Marital status
Single
Unmarried
Widowed Surviving Civil Separated

Partner
2.6 Date of birth
12/04/1976
2.7 Place of birth

WINDHOEK - NAMIBIA
2.8 Country of birth

NAMIBIA
2.9 Nationality
NAMIBIA
2.10 Do you hold any other nationalities?
No
19 Bolton Street
Mayfair, London, W1J 8BL
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
info@breytenbachs.com
www.breytenbachs.com
1A list of partners is available upon request
Regulated by the Solicitors Regulation Authority
2.11 If ‘yes’ please provide details
Part 3: Passport information
3.1 Current passport or travel document number

M0003158
3.2 Place of issue

Windhoek Namibia
3.3 Date of issue
15/08/2008
3.4 Date of expiry
15.08/2013
3.5 Is this your first passport?
No
3.6 If ‘No’ give details of previous passports covering the last ten years
3.7 Where are any previous passports?

Returned to Home Affairs, Windhoek, Namibia
Part 4: Your contact details
4.1 Your full residential address and postal code

72 KLEINE PALACE, KLEINE KUPPE, WINDHOEK, NAMIBIA
4.2 Home (landline) telephone number)

+264 61 251110
4.3 Mobile telephone number
+264 81 242 64 59
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
4.4 Email address
andreleroux12@gmail.com
4.5 Contact details if different from above
Part 5a: Your family
5.1 Is your partner accompanying you or joining you later?
No - Not applicable
5.2 Full name of spouse/partner
5.3 Spouse/Partner’s date of birth
(dd/mm/yyyy)
5.4 Spouse/Partner’s place and country of birth
5.5 Do you have any children under 18 accompanying you or joining you at a later date?
No
5.6 If ‘Yes’ please provide full details about the child/children (full name, date of birth, place of birth, passport number)
Part 5b: Your parents
5.7 Father’s given name(s)

ANDREAS PIETER
5.8 Father’s family name

LE ROUX
5.9 Father’s date of birth
08/10/1951
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
5.10 Father’s place and country of birth
WARMBAD, NAMIBIA
5.11 Father’s nationality
NAMIBIA
5.12 Mother’s given name(s)
ESTHER
5.13 Mother’s family name

VISSER
5.14 Mother’s date of birth
14/06/1952
5.15 Mother’s place and country of birth
OUTJO, NAMIBIA
5.16 Mother’s nationality

NAMIBIA
Part 6: Previous applications and travel history
6.1 If you have a UK National Insurance Number, what is the number?
6.2 Have you travelled to the UK in the last ten years?
No
If ‘Yes’ please provide details (date, purpose, duration)
6.3 Have you been granted a visa for the UK in the last ten years?
No
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
If ‘Yes’ please provide details (date, purpose, duration, reference number)
6.4 Have you ever been refused a visa for any country including the UK?
No
If ‘Yes’ please provide details (date, country, reason, reference number)
6.5 Have you ever been refused entry on arrival to the UK?
No
If ‘Yes’ please provide details (date, reason, reference number)
6.6 Have you ever been in breach of your immigration conditions for the UK?
No
If ‘Yes’ please provide details
6.7 Have you ever been deported, removed or otherwise required to leave any country, including the UK?
No
If ‘Yes’ please provide details (date, country, reason, reference number)
6.8 Have you made an application to the Home Office to remain in the UK in the last ten years?
No
If ‘Yes’ please provide details (date, reason for application, granted/refused, reason (if refused), reference number)
6.9 Do you have any criminal convictions in any country (including traffic offences)?
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
No
If ‘Yes’ please provide details (date, country, offence, sentence)
6.10 Have you ever been charged in any country with a criminal offence for which you have not yet been tried in court?
No
If ‘Yes’ please provide details (date, country, offence)
6.11 In times of either peace or war have you ever been involved in, or suspected of involvement in, war crimes, crimes
against humanity or genocide?
No
If ‘Yes’ please provide details (date, country, details)
6.12 Have you ever been involved in, supported or encouraged terrorist activities in any country? Have you ever been
a member of, or given support to an organisation that has been concerned in terrorism?
No
If ‘Yes’ please provide details (date, country, details, organisation)
6.13 Have you ever, by any means or medium, expressed views that justify or glorify terrorist violence or that may
encourage others to terrorist acts or other serious criminal acts?
No
6.14 Have you engaged in any other activities that might indicate that you may not be considered a person of good
character?
No
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR
Part 7: Additional information
7.1 Is there any other information you wish to be considered as part of your application?
19 Bolton Street
Tel: +44 207 499 3111
Fax: +44 207 499 3222
DX 138876 MAYFAIR

Tier 1 (General) - Main Applicant Questionnaire Country)

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Tier 1 (General) – Main applicant questionnaire

Part 2: About you

2.1 Given name(s)

2.2 Family name

2.3 Other names

2.5 Marital status

Widowed Surviving Civil Separated

2.6 Date of birth

2.7 Place of birth

2.8 Country of birth

2.10 Do you hold any other nationalities?

Part 3: Passport information

3.1 Current passport or travel document number

3.2 Place of issue

3.3 Date of issue

3.4 Date of expiry

3.5 Is this your first passport?

3.7 Where are any previous passports?

Part 4: Your contact details

4.1 Your full residential address and postal code

4.2 Home (landline) telephone number)

4.3 Mobile telephone number

4.5 Contact details if different from above

Part 5a: Your family

5.1 Is your partner accompanying you or joining you later?

5.2 Full name of spouse/partner

5.3 Spouse/Partner’s date of birth

5.4 Spouse/Partner’s place and country of birth

Part 5b: Your parents

5.7 Father’s given name(s)

5.8 Father’s family name

5.9 Father’s date of birth

5.11 Father’s nationality

5.12 Mother’s given name(s)

5.13 Mother’s family name

5.14 Mother’s date of birth

5.15 Mother’s place and country of birth

5.16 Mother’s nationality

Part 6: Previous applications and travel history

6.1 If you have a UK National Insurance Number, what is the number?

6.2 Have you travelled to the UK in the last ten years?

If ‘Yes’ please provide details (date, purpose, duration)

If ‘Yes’ please provide details (date, country, reason, reference number)

If ‘Yes’ please provide details (date, reason, reference number)

If ‘Yes’ please provide details

If ‘Yes’ please provide details (date, country, reason, reference number)

If ‘Yes’ please provide details (date, country, offence, sentence)

If ‘Yes’ please provide details (date, country, offence)

If ‘Yes’ please provide details (date, country, details)

If ‘Yes’ please provide details (date, country, details, organisation)

If ‘Yes’ please provide details (date, country, details)

If ‘Yes’ please provide details (date, country, details)

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