ÓÀÅÉÆÏ ÂÀÍÝáÀÃÄÁÀ-ÀÍÊÄÔÉÓ ×ÏÒÌÀ

ÓÀØÀÒÈÅÄËÏ/GEORGIA ×ÏÔÏ
ÓÀÅÉÆÏ ÀÍÊÄÔÀ/VISA APPLICATION PHOTO

1. ÂÅÀÒÉ / Last name ÓÀáÄËÉ / First name

2. ÓáÅÀ ÂÅÀÒÄÁÉ / Other names 3. ÓØÄÓÉ ÌÀÌÒÏÁÉÈÉ ÌÃÄÃÒÏÁÉÈÉ

4. ÃÀÁÀÃÄÁÉÓ ÈÀÒÉÙÉ / Date of birth ÃÀÁÀÃÄÁÉÓ ÀÃÂÉËÉ / Place of birth

1. ÌÏØÀËÀØÄÏÁÀ / Citizenship 6.ÐÀÓÐÏÒÔÉÓ ÍÏÌÄÒÉ / Passport number

(ÏÒÌÀÂÉ ÌÏØÀËÀØÄÏÁÉÓ ÛÄÌÈáÅÄÅÀÛÉ ÌÉÖÈÉÈÄÈ ÏÒÉÅÄ) 7. ÐÀÓÐÏÒÔÉÓ ÔÉÐÉ / Type of passport

(in case of dual citizenship please indicate both)

8. ÌÖÃÌÉÅÉ ÓÀÝáÏÅÒÄÁÄËÉ ÀÃÂÉËÉÓ ÌÉÓÀÌÀÒÈÉ

Permanent address
9. ÓÀÌÖÛÀÏ ÀÃÂÉËÉ / Employer ÈÀÍÀÌÃÄÁÏÁÀ / Position
10. ÌÄÖÙËÄ, ÀÒÀÓÒÖËßËÏÅÀÍÉ ÁÀÅÛÅÄÁÉ / Spouse children under 18 years of age
ÂÅÀÒÉ/ ÓÀáÄËÉ/ ÃÀÁÀÃÄÁÉÓ ÈÀÒÉÙÉ/ ÌÏØÀËÀØÄÏÁÀ/ ÍÀÈÄÓÀÖÒÉ ÊÀÅÛÉÒÉ/
Last Name First Name Date of Birth Citizenship Relationship to applicant

11. ÓÀØÀÒÈÅÄËÏÛÉ ÌÏÌßÅÄÅÉ ÏÒÂÀÍÉÆÀÝÉÉÓ ÀÍ ÊÄÒÞÏ ÐÉÒÉÓ ÓÀáÄËÉ, ÂÅÀÒÉ, ÌÉÓÀÌÀÒÈÉ ÃÀ ÔÄË.: / Name, address and
telephone of the inviting organization or person

12. ÈØÅÄÍÉ ÌÉÓÀÌÀÒÈÉ ÓÀØÀÒÈÅÄËÏÛÉ ÚÏ×ÍÉÓ ÐÄÒÉÏÃÛÉ / Your address during your stay in Georgia

13. ÚÏ×ÉËáÀÒÈ ÈÖ ÀÒÀ ÌÉÝÄÌÖËÉ ÓÉÓáËÉÓ ÓÀÌÀÒÈËÉÓ ÐÀÓÖáÉÓÌÂÄÁËÏÁÀÛÉ ÒÏÌÄËÉÌÄ ØÅÄÚÀÍÀÛÉ?/ Have you ever been

14. ÓÀØÀÒÈÅÄËÏÛÉ ÌÂÆÀÅÒÏÁÉÓ ÌÉÆÀÍÉ /Purpose of your 16. ÓÀØÀÒÈÅÄËÏÛÉ ÚÏ×ÍÉÓ ÓÀÅÀÒÀÖÃÏ ÅÀÃÀ /
visit to Georgia Length of intended stay in Georgia
À) ÃÙÄ Á) ÈÅÄ Â) ßÄËÉ
À) Ï×ÉÝÉÀËÖÒÉ Á) ÓÀØÌÉÀÍÉ Â) ÊÄÒÞÏ Day(s) month(s) year(s)
17. ÛÄÓÅËÉÓ ÈÀÒÉÙÉ /Date of entry
Ã) ÔÖÒÉÓÔÖËÉ Ä) ÓáÅÀ
18. ÂÀÓÅËÉÓ ÈÀÒÉÙÉ / Date of departure

15. ÐÀÓÐÏÒÔÉÓ ÌÏØÌÄÃÄÁÉÓ ÅÀÃÀ / Passport valid until

19. ÛÄÓÅËÀ-ÂÀÓÅËÉÓ ÏÃÄÍÏÁÀ/ À) ÄÒÈÉ Á) ÏÒÉ Â) ÌÒÀÅÀËãÄÒÀÃÉ

ÅÀÝáÀÃÄÁ, ÒÏÌ ÀÌ ÀÍÊÄÔÀÛÉ ÌÉÈÉÈÄÁÖËÉ ÌÏÍÀÝÄÌÄÁÉ ÓßÏÒÉÀ

I declare that the information provided in this application form is correct

ÈÀÒÉÙÉ ÐÉÒÀÃÉ áÄËÌÏßÄÒÀ

Date Personal signature