Niger Visa Application Form
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1EMBASSY OF THE REPUBLIQUE OF NIGER
Photograph
2204 R Street, NW, Washington, DC 20008, USA
VISA APPLICATION FORM
Applicant’s Information
1.
Last Name:
First Name:
Date of birth:
Place of birth:
Occupation:
Nationality:
Gender:
M
F
Single
Married
Address in the USA/place of residence:
Address in Niger:
Tel: (private):
(business):
E-mail:
Date of entry in Niger:
Airline:
Flight No.:
Length of stay:
City of disembarkation:
Have you previously visited Niger?
Yes
No
When?
Purpose of visit:
Student
Diplomat
Official
Tourism
Family
Business
Other (specify):
Name of the person accompanying the applicant:
Relation:
2.
Passport Information
Passport No.:
Date issued:
Expiration Date:
3.
Emergency contacts
in Niger:
In the USA/place of residence
Last and First Name :
Last and First Name:
Tel:
Tel:
Relation to the applicant:
Relation to the applicant:
4. Certification:
I, undersigned, certify that all the information provided are correct, and that I will abide by the laws of the
Republic of Niger during my stay.
Signature:
Date:
Official Use Only: Do not write below
N
du visa: _____________________________________
o
Date de délivrance ______________________________
Validité du visa _________________________________
Signature _______________________________________
Taxes perçues __________________________________
Mention (s) _____________________________________
Tel: (202) 483-4224/4225/4226 / Fax: (202) 483-3169 /
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