Immigration Act, 2002 (Act No. 13 of 2002)RegulationsImmigration Regulations, 2014AnnexuresAnnexure A: FormsForm 11 (DHA-84) |
(DHA-84) Form 11
APPLICATION FOR PORT OF ENTRY VISA OR TRANSIT VISA
[Section 7(1)(g) read with section 10A and 10B; Regulation 8(1)]
NB: A SEPARATE APPLICATION FORM MUST BE COMPLETED IN RESPECT OF EACH ACCOMPANYING FAMILY MEMBER.
PERSONAL PARTICULARS
Surname: |
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First names (in full): |
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Maiden name: |
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Previous surname(s): |
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Y |
Y |
Y |
Y |
M |
M |
D |
D |
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Date of birth: |
Country of birth:
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Gender (write in full)
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Nationality: |
If acquired by naturalisation, state original nationality:
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Where and when was present nationality obtained:
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Passport/Travel Document Number:
______________________ Type of document: Diplomatic/Official/Ordinary Passport/Travel document/other (specify) ______________________ |
Issuing authority: _________________________________ Date of expiry: ___________________________________ |
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Permanent residential address in country of normal residence ________________________________________________________________________________ ________________________________________________________________________________ ____________________________________________________________________ Period resident at this address: ............................................................................................ |
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Country of permanent residence: .....................................
Period resident in that country: ........................ |
Telephone number: (...................) ............................. Home telephone No.: ................................................ Cellphone No.: .......................................................... E-mail address: .......................................................... |
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Occupation or profession: .................................................................................................... |
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Name of Employer, University Organisation: ........................................................................ Telephone No.: .................................................. Fax No.: .................................................... |
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If self-employed, state name, address, telephone no. and nature of business:
Name of business: ................................................................................................................ Address: ............................................................................................................................... Telephone No.: .......................................... Fax No.: .............................................................. |
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Marital status: |
Never married |
Married |
Widowed |
Separated |
Divorced |
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First name(s) of spouse: |
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Maiden name |
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Date and place of marriage
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Y |
Y |
Y |
Y |
M |
M |
D |
D |
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Date of birth of spouse: |
Nationality: ...................................... |
VISIT TO SOUTH AFRICA
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: |
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Single |
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Two |
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Multiple |
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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: ..........................................................................................................
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Names of Organisations or persons you will be contacting during your stay in the Republic: |
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Name |
Address |
Relationship |
Identity document number or permanent residence permit number of South African host, where applicable: .............................................. |
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Indicate by means of an X whichever is applicable |
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Have you at any time applied for a permit to settle permanently in the Republic? |
Yes |
No |
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Have you ever been restricted or refused entry into the Republic? |
Yes |
No |
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Have you ever been deported from or ordered to leave the Republic? |
Yes |
No |
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Have you ever been convicted of any crime in any country? |
Yes |
No |
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Is a criminal action pending against you in any country? |
Yes |
No |
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Are you an unrehabilitated insolvent? |
Yes |
No |
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Are you suffering from tuberculosis or any other infectious or contagious disease or any mental or physical deficiency? |
Yes |
No |
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Have you ever been judicially declared incompetent? |
Yes |
No |
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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 |
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Give particulars if reply to any of the questions above is in the affirmative: ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ............................................................................................................................................... ...............................................................................................................................................
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In the case of an official visit, submission of a Note Verbale. |
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In the case of a diplomat placed in the Republic, proof of placement. |
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To be completed only by passengers in transit to another country: |
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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) ............................................................................................................................ |
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I ________________________________________________________________________________ (surname and name of applicant) declare that
Signature of applicant Date |
FOR OFFICIAL USE |
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Approved/not approved by ......................................... on ................................... |
Type of visa: ................................................. ................................................. |
Reasons for decision: ............................................. ............................................. .............................................. |