Chile Visa Application

Deliver / Mail / Drop-off to a location that is closest to your jurisdiction:
2200 Pennsylvania Ave NW 45 West 34th St. Suite 703
323 Geary Street, # 815
4th Floor E.
San Francisco, CA 94102
New York, NY 10001
Washington, DC 20037
Toll Free 1-877-917-7705
Toll Free 1-877-203-2551
Toll Free 1-877-400-0235
Fax 1-866-835-4372
MANDATORY ORDER FORM
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REGISTRATION WITH US EMBASSIES
The world unfortunately is not a safe place. When you travel abroad and surrounded by
foreign environment many situations, in some cases hostile may arise, like terrorist
attacks, banditry or even war. Plus there are natural disasters and catastrophes.
Visacenter.us can help you to make your contact information in the country where you
are traveling available to US Embassy/Consular officials responsible for helping
Americans abroad.
What is the registration?
Upon your request the Department of State in Washington DC will be provided with
your major contact information in the country of your travel. In the event there is a need
to contact Americans to offer urgent advice or evacuation during a natural disaster or
civil unrest, US Embassy/Consulate contacts all registered US citizens in that country.
U.S. consular officers assist Americans who encounter serious legal, medical, or
financial difficulties.
OFFICIAL REGISTRATION IS RECOMMENDED for ALL Americans traveling
abroad for business or pleasure, or residing abroad, irrespectively of the length of travel.
It is best to register BEFORE the start of the trip.
What should I do to register?
To register, you are required to fill-out short US Embassy Registartion Request Form
with your basic contact and travel information.
What is the cost?
The cost of peace of mind is just USD10.00 per person.
□ Yes, I want to register and agree that Visacenter.us submits on my behalf my data
exactly as provided by myself on the form for US Embassy Registartion service by The
Bureau of Consular Affairs of the US Department of State and agree that for this act
the charge of CAD 10.00 be added to the total payment for my visa services order.
Signature: __________________________________ Date: ____________________
Next step:
→ Please, fill-out the following US Embassy Registration Request Form
US EMBASSY REGISTRATION REQUEST FORM
BASIC INFORMATION
FIRST NAME
LAST NAME
DATE OF BIRTH
MONTH
DAY
GENDER
M/
F
YEAR
CITIZENSHIP PASSPORT
PASSPORT NUMBER
PASSPORT DATE OF ISSUE
MONTH
DAY
YEAR
MONTH
DAY
YEAR
PASSPORT DATE OF EXPIRATION
HOME RESIDENCE
ADDRESS 1
ADDRESS 2
CITY
STATE
ZIP CODE
CONTACT EMAIL ADDRESS
DESTINATION INFORMATION
COUNTRY
PURPOSE OF VISIT
DESTINATION DATE OF ARRIVAL
MONTH
DAY
YEAR
MONTH
DAY
YEAR
DESTINATION DATE OF DEPARTURE
TYPE of RESIDENCE
HOTEL
HOME
SCHOOL
OTHER
ADDRESS at DESTINATION
CITY
PHONE NUMBER AT DESTINATION
Note: If you have more than one destination please, provide details on a separate sheet of paper.
DATE:
MONTH
DAY
YEAR
SIGNATURE:
Embajada de Chile en Canada
Embassy of Chile in Canada
Ambassade du Chili au Canada
DIPLOMATIC/OFFICIAL VISA
A.-PERSONAL INFORMATION
A.- INFORMATION PERSONNELLE
1.- LAST NAME: (As shown in your passport)
1.- Nom: (comme dans le passeport)
3.- GENDER:
3.- GENRE
F:_____
VISA DIPLOMATIQUE/OFFICIELLE
2. FIRST AND MIDDLE NAME: (As shown in your passport)
2. Prénom(s) : (comme dans le passeport)
4.- PLACE OF BIRTH: (City, Province, Country)
4.- LIEU DE NAISSANCE: (Ville, Province, Pays)
M: _____
5.- DATE OF BIRTH: (DD/MM/YYYY)
5.- DATE DE NAISSANCE: (JJ/MM/AAAA)
6.- CITIZENSHIP: (Current and others)
6.- NATIONALITE: (Actuel et autres)
7.- PASSPORT Nº / TRAVEL DOCUMENT:
7.- NOMBRE DU PASSEPORT/ DOCUMENT DU VOYAGE :
8.- EXPIRATION DATE: (DD/MM/YYYY)
8.- DATE D’EXPIRATION DU PASSEPORT : (JJ/MM/AAAA)
9.- MARITAL STATUS:
9. SITUATION DE FAMILLE:
10.- LENGTH OF STAY:
10.- DURÉE DU SÉJOUR:
Single_______ Married_____ Widowed___ Separated___ Divorced___
Célibataire____ Marié_______ Veuf______ Séparé_____ Divorcé ___
11.- DEPARTURE DATE: (DD/MM/YY)
11.- DATE DU DÉPART: (JJ/MM/AAAA)
Months/Mois:______ Weeks/Semaines:______ Days/Jours:______
12.- ADRESS IN CANADA: (Number, Street, Unit , City, Province, Postal Code)
12.- ADRESSE AU CANADA: (Nombre, Rue, Appartement, Ville, Province,
Code Postale)
13.- PURPOSE OF YOUR VISIT:
13.- RAISON DE VOTRE VISITE:
14.- EMPLOYER:
14.- EMPLOYEUR:
15.- JOB TITLE:
15.- TITRE DU TRAVAIL:
B.-FAMILY MEMBERS: (if accompanying you to Chile)
B.- MEMBRES DE FAMILLE : (Si ils vous accompagnent au Chili)
1.- LAST NAME: (As shown in your passport)
1.- NOM : (comme dans le passeport)
2. FIRST AND MIDDLE NAME: (As shown in your passport)
2. PRENOM(S) : (comme dans le passeport)
3.- GENDER:
3.- GENRE:
4.- RELATIONSHIP:
4.- RELATION FAMILIERE:
F:_____
M: _____
5.- DATE OF BIRTH: (DD/MM/YYYY)
5.- DATE DE NAISSANCE : (JJ/MM/AAAA)
6.- CITIZENSHIP: (Current and others)
6.- NATIONALITE: (actuel et autres)
2.1.- LAST NAME: (As shown in your passport)
2.1.- NOM: (comme dans le passeport)
2.2.- FIRST AND MIDDLE NAME: (As shown in your passport)
2.2.- PRENOM(S): (comme dans le passeport)
2.3.- GENDER:
2.3.- GENRE:
2.4.- RELATIONSHIP:
2.4.- RELATION FAMILIERE:
F:_____
M: _____
2.5.- DATE OF BIRTH: (DD/MM/YYYY)
2.5.- DATE DE NAISSANCE : (JJ/MM/AAAA)
2.6.- CITIZENSHIP: (Current and others)
2.6.- NATIONALITE: (actuel et autres)
3.1.- LAST NAME: (As shown in your passport)
3.1.- NOM : (comme dans le passeport)
3.2.- FIRST AND MIDDLE NAME: (As shown in your passport)
3.2.- PRENOM(S) : (comme dans le passeport)
3.3.- GENDER:
3.3.- GENRE:
3.4.- RELATIONSHIP:
3.4.- RELATION FAMILIERE:
F:_____
M: _____
3.5.- DATE OF BIRTH: (DD/MM/YYYY)
3.5.- DATE DE NAISSANCE : (JJ/MM/AAAA)
3.6.- CITIZENSHIP: (Current and others)
3.6.- NATIONALITE: (actuel et autres)
Embajada de Chile en Canada. Embassy of Chile in Canada. Ambassade du Chili au Canada
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Embajada de Chile en Canada
Embassy of Chile in Canada
Ambassade du Chili au Canada
C.-ADDITIONAL INFORMATION:
C.- INFORMATION ADDITIONNELLE:
Have you or any of your family members:
Est-ce que vous ou quelqu’un de votre famille :
31. - In the last years, suffered pulmonary tuberculosis or H1N1 or have been in contact with a person with
pulmonary tuberculosis or H1N1?
YES/OUI
NO/NON
YES/OUI
NO/NON
YES/OUI
NO/NON
34. - Have requested any Chilean immigration visa? (Permanent resident, Student, Work, Visitor,
Temporary Resident, etc.)
34. – A demandé n'importe quel Visa Chilienne d'immigration ? (Résident, Etudiant, Travail, Visiteur,
Résident Temporaire, Etc.)
YES/OUI
NO/NON
35. - Have been denied a visa to travel to Chile?
YES/OUI
NO/NON
YES/OUI
NO/NON
31.- A eu tuberculoses pulmonaire ou H1N1 ou a eu contact avec une personne qui a eu une de ces
maladies, pendants les dernières années ?
32. - Committed, been arrested, or have been accused from any offence in any country?
32.- Engagé, être arrêté ou avoir accusés de n'importe quelle offense dans n'importe quel pays?
33. - Have been denied access to Chile, or been requested to leave Chile?
33. – a eu nié l'accès au Chili, ou a été demandés de quitter le Chili ?
35. - A été niés une visa pour voyager au Chili ?
36.- During peace or war times, have been involved in the execution of a war crime or a crime against
humanity, for example; assassination, torture, aggression, summit to slavery, deprive civilians or war
prisoners from food or in the deporting of civilians?
36.- Durant des périodes de paix ou de guerre, a été impliqués dans l'exécution d'un crime de guerre ou
d'un crime contre l'humanité, par exemple ; l'assassinat, torture, l'agression, esclavage, priver aux civils
ou aux prisonniers de guerre de la nourriture ou dans l'expulsion de civils ?
If YES, please give details: (you may add an extra page if needed)
Si OUI, fournissez svp les détails: (vous pouvez ajouter une page supplémentaire si nécessaire)
37.- YOUR CONTACT INFORMATION:
37- VOTRE INFORMATION DU CONTACT:
Phone: (Code & Number)
Téléphone: (Code & numéro)
Cellular: (Code & Number)
Cellulaire: (Code & numéro)
E-mail/Courriel:_______________________________________
(
(
)
)
AFFIDAVIT: I declare that I am aware that during my stay in Chile I may not carry out gainful activities nor intervene in its internal policy or in acts against its Political
Constitution or the Laws, Decrees and other provisions applicable in its territory and promise, during my stay in Chile NOT to apply for a change of my status. I further declare
that all the particulars contained in this Application are true.
DÉCLARATION SOUS SERMENT : Je déclare que je me rends compte que pendant mon séjour au Chili je ne peux pas effectuer des activités rémunératrices ni intervenir dans
la politique interne ou dans des actes contre la constitution politique, les lois, les décrets dans le territoire et promet que, pendant mon séjour au Chili, je ne demanderais pas
un changement de mon statut. Je déclare aussi que toutes les informations contenues dans ce formulaire sont vraies.
DD / MM / YY
JJ
/ MM / AA
----------------------------------------------------DATE
------------------------------------------------------------------------------APPLICANT’S SIGNATURE
SIGNATURE DU SOLLICITEUR
Embajada de Chile en Canada. Embassy of Chile in Canada. Ambassade du Chili au Canada
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