PERSONAL DETAILS BENMAR CUSTOMER REQUEST FORM

BENMAR CUSTOMER REQUEST FORM
PERSONAL DETAILS
Surname & Initials
Address
Title (Mr / Mrs / Ms / Miss)
Nationality
Telephone
VISA REQUIREMENT
Country
Purpose of Trip
(business / tourism)
Dates
From:
/
/
To:
/
/
From:
/
/
To:
/
/
From:
/
/
To:
/
/
Entries
(single / double / multi)
TIMESCALE
Please advise (if you are travelling in the meantime) the date you require your passport
PASSPORT REQUIREMENT (tick relevant boxes)
[ ] New or Renewal Standard-size Adult Passport
[ ] New or Renewal Standard-size Child Passport
[ ] New or Renewal Large-size Adult Passport
[ ] New or Renewal Large-size Child Passport
[ ] Amendment to existing Passport (name / photo)
[
[
[
[
]
]
]
]
Extension to existing passport
Second Passport ! Standard-size
Second Passport ! Large-size
Gender Change
RETURN / DELIVERY (tick relevant boxes)
[ ] Royal Mail Special Delivery Post
[ ] Airport Delivery to
[ ] Personal Collection from Benmar Office
[ ] Other Method (please give details):
[ ] Courier Delivery
If documents to be delivered to an address other than that shown above, please indicate the address here:
PAYMENT ( Travel Agents & Companies will be invoiced if previously known to us)
Benmar Fee
Delivery Charge
VAT
Embassy Fee
Total Amount
£
:
:
£
:
:
£
:
:
£
:
:
£
:
:
NB: If enclosing cheque please write name, address and telephone number clearly on reverse of cheque.
CREDIT CARD PAYMENT (or Cheque Enclosed. Please call us if you prefer to pass details by phone.)
Card Type: [ ] Visa
[ ] Visa Debit
[ ] Master Card
[ ] Amex *
Card Number:
Signature:
Expiry Date:
Date:
Card Security Code **:
** Chip and Pin requirement last 3 numbers from reverse of card
ENCLOSURES (tick relevant boxes - bold underlined items are required for all applications)
[ ] Letter of Invitation or Sponsorship [ ] Proof of Funds
[ ] Passport(s)
[ ] Evidence of Medical Insurance
[ ] Other:
[ ] Photograph
[ ] Vaccination Certificate(s)
[ ] Cheque or Credit Card Details
[ ] Visa or Passport Application Form(s) [ ] Evidence of Hotel Booking
Please send this form, with all relevant supporting documents, by special delivery to:
Benmar Passport & Visa Service Ltd. 14 Buckingham St,London WC2N 6DF
Do not be concerned if your submission is incomplete or incorrect, we will contact you immediately to
resolve any issues arising from your application.
Benmar Passport and Visa Service Limited. Registered Company Number 1934378. [email protected]. Every
care is taken to ensure that all information is present and correct. Errors and Omissions Excepted. Last update July 12
Formulaire de demande de visa / Visa application form
Titre/Title ......................... Nom/Surname ................................................................................................
Prénoms/Forenames ..................................................................................................................................
Date et lieu de naissance/Date and place of birth ……../……../…….. …………………….…….....…..
Nationalité/Nationality …………………………………………………………………………………..
Adresse/Address …………………………………………………………………………………………
....................................................................................................................................................................
Tel ........................................... Fax ......................................... Email ......................................................
Profession/Occupation …………………………………………………………………………………..
Genre de passeport/Passport type Ordinaire/National
Diplomatique/Diplomatic
Service/Official
Numéro du passeport/Passport number ...................................................................................................
Délivré à/Issued at ..............................………………… le/on ........../.......... (mois/année-month/year)
Date d’arrivée/Date of arrival ........./........./.......... Date de sortie/Date of departure ......../........./...........
Durée de séjour prévue/Expected duration of stay ...................................................................................
Nombre d’entrées/Number of entries during stay .....................................................................................
Adresse au Niger/Address in Niger...........................................................................................................
...................................................................................................... Tel ………………..............................
Motif du voyage/Purpose of current trip ...................................................................................................
Moyen de transport/Means of transport ....................................................................................................
Avez-vous un billet aller-retour/Do you have a return ticket?
Oui/Yes
Non/No
Avez-vous visité le Niger avant?/Have you visited Niger before?
Oui/Yes
Non/No
Quand/When?............................................. Pourquoi/Why? ....................................................................
Personne à contacter en cas d’urgence/Emergency contact.......................................................................
....................................................................................................................................................................
Signature du demandeur/Applicant’s signature .................................................. Date........./........./.........
Les voyageurs d’affaires seulement/Business travellers only;
Nom de société/Company name ..............................................................................................................
Adresse de société/Company address .......................................................................................................
………………………………………………………………………Tel…..............................................
Email...................................................................Web................................................................................