1. | Surname (family name)…………….. ……………..………….. ………….. …………….. ……………….… | ||||||||
2. | First names (in full) ……….. …….. …………….. …………….. ………………. ……………… ……….… | ||||||||
3. | Maiden name (if applicant is or was a married woman) ……….………….. …………………….…………............ | ||||||||
4. | Sex Male Female | ||||||||
5. | Marital Status Single Married Divorced Widow Widower Separated | ||||||||
6. | Birth: (a) Date……………………(b) City…………………………(c) Country…………………………..………. | ||||||||
7. | Nationality (if acquired by naturalisation, state original nationality) …………..………………………….……….. | ||||||||
8. | Passport: | ||||||||
(a) Number………………………(b) Issuing authority…………………………………………………………….. | |||||||||
(c) Date of expiry….…(d) Is passport valid for travel to South Africa? Yes No | |||||||||
9. | (a) Prent address…………………………………….. ………………………………………………….……….. | ||||||||
(b) Period resident at this address…………………Telephone No……………………………………….…........... | |||||||||
10. | (a) Country of permanent residence……………….. ………………………..………………………….………….. | ||||||||
(b) Period resident in that country……………….. ………………………..……………………………………….. | |||||||||
11. | Occupation or profession……………….. ………………………..…………………………………….…………... | ||||||||
12. | (a) Name of firm, company, university, aid organisation, etc., to which you are attached, attend or which you | ||||||||
reprent………….. ………………………..……………………………………………………………………….. | |||||||||
(b) Address of 12 (a) ………….. ……………….. ……Business Telephone No…………………………………... | |||||||||
(c) If attached to or enrolled as a student at a university, state faculty or cour followed…………………………. | |||||||||
(d) If you contribute professionally or otherwi to publications, radio, television or films, give | |||||||||
details……………….. ………………………..…………………………. ……………………………….………... | |||||||||
13. | (a) What is the object of your visit? ………………..…………………………. …………………………………… | ||||||||
(b) if for business how often do you travel to South Africa? …………………. …………………………………… | |||||||||
14. | (a) Duration of intended stay in South Africa (number of days, weeks or months) ………………………………... | ||||||||
(b) Propod residential address………………..…………………………. ……………………………………….. | |||||||||
Note: State full address (not box numbers) A letter from the person you intend visiting will facilitate | |||||||||
consideration of application | |||||||||
(c) If the object of visit is medical treatment, state: | |||||||||
(i) Name of doctor, hospital or clinic you will visit………………………. ……………………………………….. | |||||||||
(ii) Who will pay your medical expens and hospital fees………………. ……………………………….………. | |||||||||
(iii) If you yourlf are to be paying the expens and fees above, state amount of funds | |||||||||
available………………. …………………………………. …………………………………. ……………………. | |||||||||
Note: A certificate from your doctor confirming the arrangements must be attached | |||||||||
(d) | Name of firm, sponsoring organization, institution, relatives, friends, etc., you will be contacting during your | ||||||||
visit: | |||||||||
Name | Address | Nature of business or relationship | |||||||
………………… | ……………………….. | …….……………………………………………... | |||||||
15. | (a) How often do you intend to visit the Republic? | ……….…….………………………….. ……….. | |||||||
(b) date of last visit, if any, to South Africa | ………………………….. …………………........ | ||||||||
16. | If accompanied by your wife and children state: | ||||||||
First names | Date of birth | Place of birth | |||||||
…………………….. | …………………. …… | …………...…………………. ……….. | |||||||
…………………….. | …………………. …… | …………...…………………. ……….. | |||||||
Note:- parate forms must be completed in respect of children over the age of 16 years and | |||||||||
children traveling on their own passports | |||||||||
17. | Have you at any time applied for a permit to ttle permanently in South Africa? | Yes No | |||||||
18. | Have you ever been restricted, or refud entry into South Africa? | Yes No | |||||||
19. | Have you ever been deported from or ordered to leave South Africa? | Yes No | |||||||
20. | Have you ever been convicted of any crime in any country? | Yes No | |||||||
21. | Are you suffering from tuberculosis, any other infectious or contagious dia of any | ||||||||
mental or physical deficiency? | Yes No | ||||||||
22. | Particulars if the reply to or more of questions 17 to 21 is in the affirmative ……………………………………… | ||||||||
TO BE COMPLETED ONLY BY PASSENGERS IN TRANSIT TO A COUNTRY OUTSIDE SOUTH AFRICA | |||||||||
23. | (a) Destination after leaving South Africa…………………………………………………..………………………. | ||||||||
(b) Mode of travel to destination……………………………………………………………………………………. | |||||||||
(c) Is your entry to that destination assured, e.g. do you hold a visa or permit for permanent | |||||||||
or temporary residence (proof to be submitted)? ……………………………………………………………............ | |||||||||
. | (d) Intended date and port of departure from South Africa to that destination……………….. ……………………. | ||||||||
………………………………………………………………………………………………………………………. | |||||||||
I solemnly declare that the above particulars given by me are true in substance and in fact I fully understand the | |||||||||
meaning thereof. | |||||||||
I do not contemplate employment or study in South Africa. | |||||||||
Date……………………….19……………… Signature of applicant……………………………... | |||||||||
FOR OFFFICIAL USE ONLY | |||||||||
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