äðåîú

Photograph

Instructions for completing application form: :ñôåèä éåìéîì úåàøåä

1. Please attach a recent photograph. .äðåøçàì äîìåöù äðåîú óøöì àð .1
2. If application is not for the purpose of visit, specify øå÷éá úøèîì äðéàù ìàøùéì äñéðëá øáåãî íà .2
reasons and supply documentation. .íéëîñîå øáñä áúëî óøöì àð
3. Please fill in following details in Hebrew or English. .úéìâðàá åà úéøáòá íéàáä íéèøôä úà àìîì àð .3
÷éúä øôñî
ãáìá ãøùîä ùåîéùì
For official use only

íéîãå÷ä úåîùä íàä íù áàä íù éèøôä íùä äçôùîä íù

Previous family name Mother’s name Father’s name Given name Family name
úéøáòá
In English

ãéä çìùî úåçøæàä äãéìä êéøàú äãéìä õøà úãä

Occupation Nationality Date of birth Country of birth Religion
úéøáòá
In English

øáòîä úãåòú ïåëøãä éúçôùîä áöîä

Laisser passer Passport Family status
ãò ó÷åúá êéøàúá ïúéð øôñî éåùð ÷ååø úéøáòá
ïîìà ùåøâ
Valid untill Issued at Number Married Single
In English
Widowed Divorced

Purpose of entry into Israel: :ìàøùéì äñéðëä úøèî

Particulars of dependants included in the application äù÷áá íéììëðä ìù íéèøô

Spouse âåæä úá/ïá

äãéìä êéøàú äãéìä õøà áàä íù íéøåòðä íù éèøôä íùä äçôùîä íù

Date of birth Country of birth Father’s name Maiden name Given name Family name
úéøáòá
In English

Children under the age of 18 18 ìéâ ãò íéãìé

äãéìä êéøàú äãéìä õøà éèøôä íùä

Date of birth Country of birth Given name
In English úéøáòá In English úéøáòá In English úéøáòá
1
2
3
4

* The form continues on the back of the page óãì øáòî êùîä * 33 / ìò
.øåøéáì äëùìì êúåðôá äæ øåùéà êîò àáäå äæ øåùéà ìò øåîù .äøâàä íåìùúìå äù÷áä úùâäì àúëîñà ùîùî äæ øåùéà :äøòä
.íéúåøéù úøâà ìåá åéìò ÷áãåä àì íà ó÷åú ìë äæ øåùéàì ïéà
Note: This certification may be used as a proof for the submission of the application and for paymant of fees. Keep this certificate and produce it whenever dealing
with matters concerning this application. This certificate is not valid unless it carries a service fee stamp.
 ïåôìèä øôñî ì"åçá òåá÷ä ïòîä
Telephone No Permanent address abroad
úéáä øôñîå áåçøä øéòä õøàä
úéøáòá
Street and house No Town Country
In English

:á ìàøùé úåâéöðì øéáòäì àð äù÷áä øåùéà ìò äòãåää úà

On notification of permit, please inform Israeli Representative Office in:

Declaration äøäöä

àì .úéìéìô äøéáò éúøáò àìù äæá øéäöî éðà ,ïë åîë .éúù÷áá ïåéãì ãåñé íéååäî íäù äøëäá åøñîðå íéðåëð ìéòì åøñîðù íéèøôäù øéäöî éðà
é"ò ù÷åáî éððéàå éèåôéù øöòî åö éãâð íéé÷ àì .øåáéöä úåàéøá úà ïëñì äìåìòä äìçîá éúéìç àì .ìàøùé úðéãî ïåçèáå éãåäé íòä ãâð éúìòô
.éäùìë äðéãî ìù äøèùîä

I declare that the particulars contained in this application are correct and have been made in awareness of the fact that they are to serve
as basis for the consideration of my application. I also declare that I have not committed any criminal offence or any act directed against
the Jewish people or the security of the State of Israel and that I am not affected with any illness which might endanger public health. There
is no judicial warrant of arrest against me and I am not wanted by the police of any country.

øúåéîä úà ÷åçîì àð * .2
(íé)éàøçà (å)éðà .äøåîàä äôå÷úì õøàì åúñéðë øçàì ì"ðä úà ÷éñòäì (íé)áééçúî (å)éððäå íéðåëð íä (åð)éúøñîù íéèøôäù (íé)øùàî (å)éðà
(øåñîð)øåñîà êë ìò äòãåä .øúåé íã÷åîä ãòåîä éôì ,åðãñåîá åãé÷ôú øîâá åà ïåéùøä ãòåî íåú éðôì ìàøùé úà (å)áåæòé åéìà íéååìéðäå ïîæåîäù
.äìàë úåàöåä äðééäú íà ì"åçì ì"ðä úøæçäì øù÷á äì äéäúù äàöåä ìë äìùîîì ÷ìñì (íé)áééçúî (å)éðà .íéðôä ãøùî ,íùøîå äéìòì äëùìì
.õåç òáèîá åäùìë íåìùú åà øëù *ìá÷é àì / ìá÷é ïîæåîäù äæá (íé)øéäöî (å)éððä
2. * Delete whichever is inapplicable
I (we) certify that the particulars contained in this application are correct and I (we) undertake to employ the a/m, after his arrival to Israel,
for the period stated. I (we) am (are) responsible that the said person and the persons accompanying him will leave Israel before the expiry
of his (their) permit of residence or upon the termination of his employment by me (us) whichever is the earlier event. I shall notify the district
office of the Population Administration, Ministry of the Interior, of his departure. I undertake to reimburse the Government for any expense
which may be incurred in connection with the deportation of the said person or persons. I declare that the person for whom the visa is
requested *will / will not receive a renumeration of other payment in foreign currency.

Signature of applicant: :ù÷áîä úîéúç Date: :êéøàúä Place: :íå÷îä

äñðëä ìåá

Fincal stamp
ãñåîä åà ìòôîä úîúåçå ïéîæîä úîéúç
Signature and official stamp of establishment or institution

For official use only ãøùîä ùåîéùì

:íåéá :íå÷îá äìá÷úð äù÷áä
:ìá÷îä ãé÷ôä úîéúç :ìá÷îä ãé÷ôä íù
øîåçä á"åöø úåøòä ïéà ù"îøá ÷ãáð
úòáèäì íå÷î äáøåñ äù÷áä äøùåà äù÷áä
ïåéùøä úîúåç :ãé÷ôä úîéúç :ãé÷ôä íù :êéøàú

ù÷áîì äçìùð áåøéñ ìò äòãåä

÷éúì óøåöî åðîî ÷úòäù áúëîá

33 / ìò