3-1/0033

FOR OFFICIAL USE ONLY

Approved / Not Approved
Single/Multiple entry

PSkNoj.
Pate of issue:.
REPUBLIC OF NAMIBIA Date of expiry:.
Ministry of Home Affairs and Immigration
Immigration Control Act, 1993 Remarks:

APPUCATION FOR VISA

(Sections 12 and 13 / Regulation 11)
hems 4to 10 to be completed by inserting an "X". in the appropriate box.

1. Surname: Signature:.
2. First name*:. Date:
3. Maiden name (if applicant is or was a married woman):
4. S«x: Male P«n.V 5. Marital status: Never Married Married Divorced Widow/Widower
6. Haveyoaatanytir«apDlicdforaDOTnittosettleperinanenliyinNaniibia? Yesl 1 i
[NO =
7. Have you ever been restricted or refused entry to Namibia?
8. Have you ever been deported or ordered to kave Namibia?
%sl
Yes
r
No
Nol
9. Have you ever been convicted of any crimefin any country? Yes ran f

11 .If me reply to any one of mequestions 6to 10 ism me affirmative, attach fnD particulars.
12. Birm (a) Date: (b) Place: , _ Country.
13. Citizenship: _:
14. Passport (a) Number: (D) Place of issue.
(c) Date of issue: '. (d) Date of expiry:.
(e) Is passport valid for travel to Namibia:
IS. (a) Present residential i
_(b) Telephone no.: (.
16. Address and period of residence in country of which you are a] t resident:
(a) Residential address: ,
Cb) Telephone no.: ( ) .(c) Period:.
17.'Occupation or Profession: -
18. Firm, cainpany.uinversny, etc,, to wrrich you are attach
(a) Name and address of employer: ^
(b) Telephone no.: (_ ) , .
(c) Nature of business: ' ;
<d) If a student, name of university to which you are attached and the coarse pi
19. S accompanied by your wife and children state:
First Names DateofBirta Place of Birth

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<c)
20. (a) What amount of money wul you have available on arrival in Namibia for your own use?VN$.
(b)Wm yon be m possession of an ~
a^a^K a^f 1C V^aW a
 NOTE: COMPLETE ONLY PART AOR B
(A)HOUDAY/BGSINESS/WORK/TRANSn/VISA
1. Intended date and port of arrival m Namibia: ; :_
2. (a) What is me purpose of you visit?
(b) If it is for business purposes, explain in detail me nature of business:.

(c) Duration of intended visit (Number of days, weeks or months).

3. Places tobe visited m NanriWa (fM address, nxtotag tekphoo^

4. If me purpose of yoar visit is for medical treatment, please provide the fottoying information:
(a) Name of doctor, hospital or dink you wffl visit: _
(b) Who will pay your medical expenses and hospital fees:.
<c)If you are liable for the expenses and fees above, state amount of ftmds available:.
5. Proposed residential address in Namibia:
JIekpjlioneno.:(_
6. Names and addresses of relatives in Namibia:
Nam* AddRHaodtTUcvboawBinuber fTfffrt^^irfr
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7. Date of last visit, if any, to Namibia: ,

8. Do yon conttibnte professionally w

9. (a) Destination after leaving Namibia:

{b) Mode of travel to destination: • -
(c) blended dale and poet of departure:
(d)Isyowen»rytoliiatdestinationass

10. Reasons for travelling through Namibia:

(B)SETUBNVEA r :

IMPCHTCANT -
An applicant has to:
© produce his or her passport or travel document; and
m^
1. (a) Kindof Petnnt andntonber..
(b) Date of t
(c) Expected date of return:.
2. Partfcolara of Residence in Namibia:
i nNMBs 01 naaoncB
Ttia^ n ttm -m
• m^am
•*-— -- ^ l^a^^UA

IMeoTflnt cater Port of catty v9m

nom • ' • n^k
10

3. Couotries to which you wfll be travelling:

(a) : (b).
4. Puposeof journey (explain fuBy):

^ I scdenmtydedace that tte above particulars arefraemnlMtaQwandia

Date: ^, •.
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