ambassade de la republique democratique du congo a

AMBASSADE DE LA REPUBLIQUE DEMOCRATIQUE DU CONGO
A PRETORIA
DEMANDE DE VISA--VISA APPLICATION
NOM (Surname)……………………...PRENOM (Names)……………………………..…………………………………………………………………………………
LIEU DE NAISSANCE (Place of birth): …………………DATE DE NAISSANCE (Date of birth):
……………..........................................................................................................
SEXE (Sex): ……………………………ETAT CIVIL (Marital status)………………………………………………………………......................................................
NATIONALITE D’ORIGINE (Nationality at birth)……………….NATIONALITE ACTUELLE (Current nationality)……………………………………………….
PROFESSION (Occupation)………………………………TELEPHONE(H)………………………(CELL)…………………………………………………………....
ADRESSE DE RESIDENCE (Residential address)………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………
EMPLOYEUR (employer)……………………………………TEL………………………………..E-MAIL…………………………………………………………….
ADRESSE (ADDRESS)……………………………………………………………………………………………………………………………………………………
TYPE DE PASSEPORT (Type of passport)
(
(
(
(
) ORDINAIRE (Ordinary)
) SERVICE (official)
) DIPLOMATIQUE (Diplomatic)
) AUTRE, SPECIFIER (other, specify)
NUMERO DU PASSEPORT (passport number)…………………………………………………………………………………………………………………………
LIEU ET PAYS D’EMISSION (Place & country of issue)………………………………………………………………………………………………………………
DATE DE DELIVRANCE (date of issue)…………………………………………………………………………………………………………………………………
DATE D’EXPIRATION (Expiry date)…………………………………………………………………………………………………………………………………….
MOTIF DU VOYAGE (Purpose of visit)…………………………………………………………………………………………………………………………………
DATE D’ENTRÉE EN RDC (Date of entry in DRC) ………………………………………………………………………………………………………………….
DUREE DU SEJOUR (Duration of journey)………………………………………………………………………………………………………………………………
PORT D’ENTRÉE EN RDC (Point of entry in DRC)……………………………………………………………………………………………………………………
MOYEN DE VOYAGE (Means of transport):
( ) ROUTE-ROAD ( ) AVION-AIR ( ) BATEAU- SEA ( ) OTHER
REFERENCE EN RDC (references in DRC)
NOMS (Names)
1………………………………………….
2………………………………………….
ADRESSE (ADDRESS)
……………………………
……………………………
TELEPHONE
…………………………………………………..................
………………………………………………………..........
ENFANTS ACCOMPAGNANT LE DEMANDEUR-CHILDREN (MINOR) ACCOMPANYING THE HOLDER: ( ) YES ( ) NON
NOMS (NAMES): 1…………………………………………………
3 …………………………………..……………...
SIGNATURE: ________________________________
FOR OFFICE USE ONLY
VISA NO:
DELIVRE LE:
REMARQUE:
2 ...........……………………………..........................................................................
4………………………..……………………………………………………...........
DATE: ________________________________________
DURE:
SIGNATURE: