Form 5a - Visa Application Form
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1
2
3
4Republic
o f
S outh
S udan
Ministry
o f
I nterior
Directorate
o f
N ationality,
P assports
a nd
I mmigration
Visa
A pplication
F orm
Form
5 A
(FILL
O UT
I N
C APITAL
L ETTERS
O NLY)
Warning: giving false information is considered a crime in accordance with the Passport and Immigration Act, 2011. Visa fees are
non-refundable. Visa is not transferable and attempt to do so is considered a crime.
Place of Application
Date:
/
/20
Have you Previously Applied for South Sudan Visa. Yes
No
If yes, Previous visa No:. ……………………………..…. Date of Issue……………………………..….Place
of Issue……………………………..….Date of Arrival in south Sudan……………………………..….Point of
Entry……………………………..…point of Exit……………………………..….
1. Visa Type Requested: Single:
Multiple:
Transit:
Other:
(Specify)
Purpose of visit: Visit
Education
Tourism
Medical treatment
Official
Other
(Specify)
…………………………..….
Duration
of
Intended
Stay……………………………..….Date
of
Intended
Arrival
in
South
Sudan……………………………..….
Mode of Transport: Air
Road/Trail
River
2. Personal Details (As in Passport)
Surname: ………………………………………………………………………………………
Given Names: …………………………………………………………………………………
Date of Birth (Day/Month/Year): ……/……../……….
Place of Birth: ………………………….Country of Birth………………………….…
Sex:
Male
Female
Marital Status: Single
Married
Divorced
Widowed
Visa
A pplication
F orm
( Form
5 A)
Page
1
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