visa request form formulaire de demande de visa imm/22a

Reserved for Administration
Réservé à l’Administration
Visa No: .…………………………………………..
Duration/ Durée: …………………………….
Reason / Motif: .………………………………
Valid Till / Valable au: …………………….
Accepted/Accordé ☐
Rejected/Refusé
☐
•
•
1.
To be completed in capital letters
A remplir en majuscules
EMBASSY OF THE FEDERAL REPUBLIC
OF NIGERIA, TUNIS
***
AMBASSADE DE LA REPUBLIQUE
FEDERALE DU NIGERIA
VISA REQUEST FORM
FORMULAIRE DE DEMANDE DE VISA
IMM/22A
FAMILY NAME / NOM: ..……………………………………………………………………………………………………………………………………………………
2. OTHER NAMES / PRÉNOM: ………………………………………………………………………………………………………………………………………………
3. DATE AND PLACE OF BIRTH / DATE ET LIEU DE NAISSANCE: ………………………………………………………………………………………………
4. NATIONALITY AT BIRTH / NATIONALITE D’ORIGINE: …………………………………………………………………………………………………………
5. PRESENT NATIONALITY / NATIONALITE ACTUELLE: ….……………………………………………………………………………………………………….
6. MARITAL STATUS / ÉTAT CIVIL: …….…………………………………………………………………………………………………………………………………..
7. PROFESSION: …………………………………………………………………………………………………………………………………………………………………….
8. PLACE OF WORK / LIEU DE TRAVAIL: ………………………………………………………………………….. TEL: ..………………………………………….
9. PASSPORT No: ………………………………….. ISSUED ON / DÉLIVRE LE: …………………………….... AT/À: ………………………………………..
10. RESIDENCE DURING THE LAST TWO YEARS / RESIDENCE AU COURS DES DEUX (2) DERNIERES ANNEES: ………………………….
11. DATE OF ENTRY TO NIGERIA / DATE D’ENTRÉE AU NIGERIA: …………………………………………………………………………………………….
12. DURATION OF STAY / DUREE DE SEJOURS(Days/Jours, Months/Mois): .…………………………………………………………………………….
13. ANTICIPATED MODE OF TRANSPORTATION / MOYEN DE TRANSPORT ENVISAGE: .…………………………………………………………..
14. POINT OF ENTRY / POINT D’ENTREE: ………………………………………………………………………………………………………………………………..
15. PERSON (S) ACCOMPANYING YOU / PERSONNES QUI VOUS ACCOMPAGNENT:…..…………………………………………………………….
16. HAVE YOU PREVIOUSLY REQUESTED FOR VISA TO NIGERIA?
AVEZ-VOUS DEJA PRESENTE UNE DEMANDE DE VISA POUR LE NIGERIA?
YES/OUI ☐
NO /NON ☐
PLACE / LIEU :……………………………………………………………………………………. DATE: ………………………………………………………….
17. REASONS FOR TRAVEL / MOTIF DU VOYAGE:
BUSINESS TRIP / VOYAGE D’AFFAIRES
TO ATTEND A MEETING/ ASSISTER À UNE RÉUNION ☐
☐
NAMES & ADDRESSES OF THE PERSON (S) TO BE CONTACTED
NOM & ADRESSES DES PERSONNES À CONTACTER
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NAME OF THE ORGANISATION / NOM DE L’ORGANISATION
------------------------------------------------------------------------PLACE// LIEU
-------------------
DATE
----------------
DURATION
----------------------
OTHERS / AUTRES ☐
TRIP FOR STUDYING OR TRAINING ☐
VOYAGE D’ETUDE OU DES STAGES
NAME OF THE INSTITUTIONS / NOM DES ETABLISSEMENTS
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ARE YOU FINANCIALLY SUPPORTED BY ANY PERSON?
ETES VOUS PRIS EN CHARGE PAR QUELQU’UN?
PERSONS KNOWN IN NIGERIA / CONTACTS AU NIGERIA
------------------------------------------------------------------------------------------------------------------------------------------------------THEIR ADDRESSES / LEURS ADRESSES
-----------------------------------------------------------------------------------------------------------------------------------------------------
I pledge not to engage in any illegal activities in Nigeria, and to leave the Nigerian territory at the expiration of the validity of
the visa which will be granted to me.
The signature below binds me and in case of false declaration will deprive me from obtaining any visa in the future without
prejudice to any further legal action according to law.
Je m’engage à ne participer à aucune activité illégale au Nigeria, et à quitter le territoire Nigerian a l’expiration de la validité
du visa qui me sera accordé.
Je m’engage par ma signature ci-dessous, laquelle en cas de fausse déclaration me priverait de tout visa à l’ avenir sans
préjudice sur les poursuites judiciaires prévues par la loi.
Date : _______________________
Signature : ____________________________
FOR OFFICIAL USE ONLY
RESERVE A L’AMBASSADE
RECOMMENDATIONS:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
APPROVAL:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________