Photo Ambassade Ambassade de la République du YEMEN A

Ambassade
de la République du
YEMEN
A BRUXELLES
Tél – 02/639 46 83
Photo
‫ ا
ا ا‬
‫ارة ة دل‬
Formulaire de demande de visa /Application Form For Entry Visa
Nom et Prénom /Full Name & Surname :----------------------------------------------------------------------------------‫ا ا
وا‬
Lieu et date de naissance/ Place & Date Of Birth :------------------------------------------------------------- --------- ‫
ن و
ر اد‬
Nationalité / Nationality : ----------------------------------------------------------------------------------------------------------------‫ا‬
Situation familiale / Marital Status :------------------------------------------------------------------------------------------- ‫ا!
ا‬
Profession / Profossion : -------------------------------------------------------------------------------------------------------------------"‫ا‬
N° du passeport / Passport No :-------------------------------------------------------------------------------------------------#$‫ر' &از ا‬
Type / Type :---------------------------------------------------------------------------------------------------------------------------------(&)
Place et date de délivrance / Place & Date Of Issne :-------------------------------------------------------------------*‫ور‬+, ‫
ن و
ر‬
Date de la validité / Expire on : -------------------------------------------------------------------------------------------(-, ‫
ر ا)"
ء‬
Enfants figurants sur le passeport / Other Names Shows In Passport : -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------‫
&از‬/ "0
‫ر أ‬+‫ة ا‬#3‫اد ا‬#4‫أ‬
Adresse permanence / Permanent Address :--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------0‫ا‬+‫&ان ا‬5‫ا‬
Objet du voyage / Purpose Of Visit : -----------------------------------------------------------------------------------------#$‫ ا‬6 ‫ض‬#8‫ا‬
Validité du visa requis / Duration Of Visa Required :-------------------------------------------------------------------/&9‫ة ا‬#:;‫ة ا‬+
Nombre d’entrée / No Of Entries Requested :-------------------------------------------------------------------------/&9‫ات ا‬#$‫د ا‬+
Durée du séjour au Yémen / Period Of Stay In Yemen :-----------------------------------------------------------------6‫= ا‬4 '‫ة ا‬+
Adresse au Yemen /Address In Yemen : -------------------------------------------------------------------------------------6‫= ا‬4 ‫&ان‬5‫ا‬
•
Je certifie que les renseignements ci hauts mentionnés sont exacts et promets de respecter les lois et les
règlements de la République du Yémen
•
I Hereby Declare That Above Information Is Correct And Fullfil The System And Laws Of Y . R
•
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Date : ------------------------------------------------------------------------------------------------‫ار‬
Signature :------------------------------------------------------------------------------------------ ‫ا‬
‫ ل ا‬- Pour usage officiel seulement / FOR OFFICIAL USE ONLY
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THE FOLLOWING ATTACHMENT TO BE SUBMITTED WITH THIS FORM‫" ! ا رة‬# $ ‫ات ا‬
VALID PASSPORT
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TWO PHOTOS 4×6
6×4 ‫ س‬6: 6‫&ر‬, -
RETURN-TICKET
HEALTH CERTIFICATE
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