Form 5a - Visa Application Form (Page 3 of 4) in pdf

Form 5a - Visa Application Form Page 3

E-mail Address:. …………………………………………………………

Next of Kin Details

Surname: …………………………………………………………

Given Names: ……………………………………………………

Permanent Address:

………………………………………………………………………….…………………………………………

……………………………………………………………………………………………

Phone No: ……………………………………………Mobile No……………………………….……….

E-mail Address: ………………………………………………………………

8. Have you ever:

a) Been convicted of a crime or offence in any country?

Yes

b) Been deported or removed from South Sudan or any country for overstaying your visa or violating any

law or regulation?

Yes

c) Been convicted and sentenced for a drug offence in any country in violation

of law concerning narcotics, marijuana, opium, stimulants or psychotropic

substances?

Yes

d) Committed trafficking in persons or incited or aided another to commit such an offence?

Yes

e) Are you suffering from tuberculosis, any other infectious or contagious disease

Yes

If you answer yes to any of the questions above, provide explanation below:

………………………………………………………………………….

……………………………………………………………………………….

Address of Place of Stay / Hotel:

………………………………………………………………………………….……

………………………………………………………………………………………

Funds Available For My Stay ………………………..

9. Guarantor or references in South Sudan:

Name: ……………………………………Telephone No.: ………………………………

Visa A pplication F orm ( Form 5 A)

Page 3

Form 5a - Visa Application Form Page 3