Surname:

First names (in full):

Maiden name:

Previous surname(s):

Y

Y

Y

Y

M

M

D

D

Date of birth:

Country of birth:

Gender (write in full)

Nationality:

If acquired by naturalisation, state original nationality:

Where and when was present nationality obtained:

Passport/Travel Document Number:

______________________

Type of document:

Diplomatic/Official/Ordinary Passport/Travel document/other (specify)

______________________

Issuing authority: _________________________________

Date of expiry: ___________________________________

Permanent residential address in country of normal residence

________________________________________________________________________________

________________________________________________________________________________

____________________________________________________________________                          

Period resident at this address: ............................................................................................

Country of permanent residence:

.....................................

Period resident in that country: ........................

Telephone number: (...................) .............................

Home telephone No.: ................................................

Cellphone No.: ..........................................................

E-mail address: ..........................................................

Occupation or profession: ....................................................................................................

Name of Employer, University Organisation: ........................................................................

Telephone No.: .................................................. Fax No.: ....................................................

If self-employed, state name, address, telephone no. and nature of business:

Name of business: ................................................................................................................

Address: ...............................................................................................................................

Telephone No.: .......................................... Fax No.: ..............................................................

Marital status:

Never married

Married

Widowed

Separated

Divorced

First name(s) of spouse:

Maiden name

Date and place of marriage

Y

Y

Y

Y

M

M

D

D

Date of birth of spouse:

Nationality:

......................................

Expected date of arrival in the Republic:   YY .................. MM ......................DD ........

Place of arrival: ............................................ Purpose of visit: .....................................................

Duration of stay (months, weeks or days) ....................................................................................

Number of entries required:

Single

Two

Multiple

Proposed residential address (physical) in the Republic, including the full name(s) of your host or hotel:

Residential (physical) Address in the Republic: ..............................................................................

......................................................................................................................................................

Name of Host or Hotel: ..................................................................................................................

Telephone of Host or Hotel: ..........................................................................................................

Names of Organisations or persons you will be contacting during your stay in the Republic:

Name

Address

Relationship

Identity document number or permanent residence permit number of South African host, where applicable:

..............................................

Indicate by means of an X whichever is applicable

Have you at any time applied for a permit to settle permanently in the Republic?

Yes

No

Have you ever been restricted or refused entry into the Republic?

Yes

No

Have you ever been deported from or ordered to leave the Republic?

Yes

No

Have you ever been convicted of any crime in any country?

Yes

No

Is a criminal action pending against you in any country?

Yes

No

Are you an unrehabilitated insolvent?

Yes

No

Are you suffering from tuberculosis or any other infectious or contagious disease or any mental or physical deficiency?

Yes

No

Have you ever been judicially declared incompetent?

Yes

No

Are you a member of, or adherent to an association or organisation advocating the practice of social violence or racial hatred or are you or have you been a member of an organisation or association utilizing crime or terrorism to pursue its ends?

Yes

No

Give particulars if reply to any of the questions above is in the affirmative:

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

...............................................................................................................................................

In the case of an official visit, submission of a Note Verbale.

In the case of a diplomat placed in the Republic, proof of placement.

To be completed only by passengers in transit to another country:

Destination after leaving the Republic: ..................................................................................

Mode of travel to destination:................................................................................................

Intended date and port of departure from the Republic to that destination: ..........................

Do you hold a visa or permit for temporary or permanent residence in the country of your destination? (Proof must be  submitted) ............................................................................................................................

I ________________________________________________________________________________

           (surname and name of applicant) declare that

Signature of applicant                                                                  Date

FOR OFFICIAL USE

Approved/not approved by

.........................................

on  ...................................

Type of visa:

.................................................

.................................................

Reasons for decision:

.............................................

.............................................

..............................................