EMBASSY OF MADAGASCAR Washington, DC USA

REPOBLIKAN’I MADAGASIKARA
Tanindrazana-Fahafahana-Fandrosoana
------------------EMBASSY OF MADAGASCAR
Washington, DC
U.S.A.
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FICHE D’IMMATRICULATION
N# …………
Nom………………………………………………….
Prenoms………………………………………………
Date de naissance…………………………………….
2
PHOTOS
Fokontany……………………………………………
Fivondronana……………………………………………………………………………….
Firaisam-pokontany………………………………………………………………………...
Faritany……………………………………………………………………………………..
Fils/Fille de (père)…………………………………………………………………………..
Et de (mère):………………………………………………………………………………..
Nationalité:………………………………………………………………………………….
Residence actuelle (adresse exacte):………………………………………………………..
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Residence habituelle à Madagascar:………………………………………………………..
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Profession:…………………………………………………………………………………..
Situation de famille:………………………………………………………………………...
Situation militaire:………………………………………………………………………….
Date d’arrivée aux Etats-Unis d’Amerique…………………………………………………
Passeport N#………………………………délivré le……………………………………...
Par:………………………………………………………………………………………….
Valide jusqu’au……………………………………………………………………………..
À………………………….le……………………………………………………………….
Signature
2374 Massachusetts Avenue, NW Washington, DC 20008 – USA Telephone:1-202-265-5525 – Fax :1-202-265-3034
Email: [email protected]