Application For Visa - Republic Of Namibia Ministry Of Home Affairs
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23-1/0033
FOR OFFICIAL USE ONLY
REPUBLIC OF NAMIBIA
Approved / Not Approved
MINISTRY OF HOME AFFAIRS
Single / Multiple Entry
DEPARTMENT OF CIVIC AFFAIRS
IMMIGRATION CONTROL ACT, 1993
File No: ____________________________
APPLICATION FOR VISA
(Sections 12 and 13 / Regulation 11)
Date of Issue: _______________________
Date of Expiry: ______________________
1. Surname: _____________________________________________________
2. First Names: __________________________________________________
3. Maiden name (if applicant is or was a married woman): ________________
____________________________________________________________
Remarks: ___________________________
ITEMS 4 TO 10 TO BE COMPLETED BY INSERTING AN “X” IN THE APPROPRIATE BOX
__________________________________
4. Sex:
Male
Female
__________________________________
5. Marital
Status
Never Married
Married
Divorced
Widow/Widower
__________________________________
6. Have you at any time applied for a permit to settle
permanently in Namibia?
Yes
No
7. Have you ever been restricted or refused entry to Namibia?
Signature: __________________________
Yes
No
8. Have you ever been deported or ordered to
Date: ______________________________
leave Namibia?
Yes
No
9. Have you ever been convicted of any crime in any country?
Yes
No
10. Are you suffering from tuberculosis, or any other contagious lung disease; trachoma, or any other chronic eye infection,
frambesia, yaws, scabies or any other contagious bacterial or other skin disease; syphilis or any other venereal disease; or
leprosy or acquired immune deficiency syndrome virus (AIDS virus), or any mental illness or affliction?
Yes
No
11. If the reply to any one of the questions 6 to 19 is in the affirmative, attach full particulars
12. Birth: (a) Date: _______________________
(b) Place: _________________
Country: __________________________
13. Citizenship: ______________________________________________ (if acquired by naturalization, state original citizenship)
14. Passport: (a) Number __________________________
(b) Place of issue: _______________________________________
(c) Date of issue ______________________________
(d) Date of expiry: ______________________________________
(e) Is passport valid for travel to Namibia?
Yes
No
15. (a) Present residential address: ____________________________________________________________________________
____________________________________________________________________________________________________
(b) Telephone number: (Code: _________________________ )
No: ____________________________________________
16. Address and period of residence in country of which you are a permanent resident:
(a) Residential address: _________________________________________________________________________________
____________________________________________________________________________________________________
(b) Telephone number: (Code: _________________________ )
No: ____________________________________________
(c) Period: ____________________________________________________________________________________________
17. Occupation or profession: _______________________________________________________________________________
18. Firm, company, university, etc., to which you are attached or which you represent: __________________________________
(a) Name and address of employer: ________________________________________________________________________
(b) Telephone number: (Code: _________________________ )
No: ____________________________________________
(c) Nature of business: __________________________________________________________________________________
(d) If a student, name of university to which you are attached and the course pursued: ________________________________
____________________________________________________________________________________________________
19. If accompanied by your wife and children, state:
FIRST NAMES
DATE OF BIRTH
PLACE OF BIRTH
(a) ___________________________ (a) ______________________________ (a) _________________________________
(b) ___________________________ (b) ______________________________ (b) _________________________________
(c) ___________________________ (c) ______________________________ (c) _________________________________
20. (a) What amount of money will you have on arrival in Namibia for your own use? N$
(b) Will you be in possession of an onward/return ticket?
Yes
No
(N.B. Separate applications have to be completed in respect of your spouse or children over the age of 16 years and children travelling with their own passports.)
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