GOVERNMENT GAZETTE, 22 MAY: (OHA-84) Form 11 DEPARTMENT OF HOME AFFAIRS REPUBLIC OF SOUTH AFRICA APPLICATION FOR PORT OF ENTRY VISA OR TRANSIT VISA, [Section 7(1)(g) read with section 108 and 108; Regulation 81) NB: A SEPARATE APPLICATION FORM MUST BE COMPLETED IN RESPECT OF EACH ACCOMPANYING FAMILY MEMBER, PERSONAL PARTICULARS ‘Sumame: Fst names infu. Maiden name: Previous sumame() ato ot i ‘County of be Gondor (tin fa) T aed By nates, He ga tony: avon” oo Winer and when was present natonality btsned Te ume se ae sn ase hPassperTravel Document Numba: Issuing authorty: Date of expiry. Type of document: DiploratiyOMicialOrcnary Passport Travel eoumentoner (spect) Permanent rider address in county of normal esdence County permanent residence: Telephone number: (2) Home telephone No. CCetphone No. E-mail adios Ptiod resident in hat county ‘Occupation or protession Name of Employer, Urivrsy Organisation Aros: Telephone No. FaxNo, ‘it ao vlna tw gevonncsNo. 7670 GOVERMENT GAZETTE, 22 MAY 2 set-empioyed, stato name, adress, telephone no, and nature of business Name of business: ‘Adee: . Telephone No, FaxNo, Maral status: | over Maried | | widowed | | Soparatog aio Ft name) of spouse: Maiden name. Date and pace of marrage Dato of bith of Natonaty visit To SOUTH AFRICA Expected date ofaivalin the Republics YY nw Place of eral Purpose o vist uration of stay (months, wooks or days) ‘Number of entries required: ‘Shae Two atte hott Fesidontal physical Address inthe Repubtc: Name of Host or Hott “Tolephone of Hest or Hote ‘pane rls rina rongpwonc bo. Proposed resiertil adress (physical inthe Repub including the fll nme) of our host o|‘Wars of Organisations oF parSons you wit be carling during your stay ina Repub Name cerees Relatonshio fen document number or pamanent eedance port numberof South Alcan host, where potable: [Teta by means Tan X whichever appicabie ‘ave You a any iro apple far apoio wate pammanenty lathe [Ves | | No pubic? ave you over boen resid orraueed ary no tha Raabe? Yea} [Ne ave you evr bean deporied fom or ordered lav the Repo? Yee} [Ne ave you ever been convicted a ay aime ay country? Yes] [Re Tea cminal aon pending agains youn any coun? Yes | [Ne "ie you an nrehabiited insoivent? Yes | [Ne ‘re you suffering rom tuberculosis of any oharefecfous or Sonlagious [Yes | | No Seease or any mental or physical defelency? ave you over been judicial daclred incompetent? Yes | [Re "he you & Member oi oF adherent fo an assosalion oF orpanieaton [Ves] | No ‘Te gn ett te on at wigan‘avocatng the practic of soil vance or TAT PAN or ae YoU Tae fn & member of an organisation or association uizing cme or ‘eros te pursue its ond? {Give parties if reply to any of the questions above isin the atrmatve: Tithe case ofan Oa ii, submicsion ofa Note Verbal {nthe case ofa diplomat placed in the Republic, proot of placement. ‘To be completed only by passengers in wansit to anathor country: ‘Dosnation for laving tho Republi Mode o travel to destination Intended dato and por of departure fom the Repu to that destination: Do you held a visa or pamit fo temporary or permanent residence in the county of your osinaton? (Proo! must be submit) ‘The pm a ts nine tgp(arname and name of applicant) declare that + the above detale provided by me are true In substance and in fact and that | fully Understand the meaning thereof, ‘+ Tunderstand that should my pert of erry visa transit visa / vistors via be approved, | would not be alowed to change my purpose of visit wht inthe Republic; + understand that If need to extend my stay Inthe Republic for whatever reason, that ‘uch an application wil only be accepted if Te eubmied at least 80 days prior to the xpi dat of my current via; and ‘+ understand that I! depart from the Republic after the expiry date of my visa, that | would be declared an undesirable person and that | would not qualify for 8 visa or {Admission Into the Republic Tora period ofa least Signature of applicant ate FOR OFFICIAL USE Approvednot approved by Type ova ‘Reasons Tor deciion ‘ha pate eo ren tm gpenne cat