Lao People’s Democratic Republic Peace Independence Democracy Prosperity ere ereeeee etree 1 Photo Embassy of the Lao P.D.R. to India and Nepal, Sri Lanka, Maldives 3emx4cm Bhutan, Bangladesh, Iran and Egypt. S-420, Greater Kailash, Part 2 New Delhi ~ 110048. Tel: +91 11 41327352 - Fax: +91 11 41327353 oceecey Email: laoembdelhi@gmail.com VISA APPLICATION FORM 1, Given Name: Family Name: -s.Middle Name: Date of Birth: Day: -Month: Year: Place of Birth: Nationality at Birth: Nationality at present: Occupation: Passport Type: o Diplomatic, o Official, o Service, « Regular, « Other (Please Specify). Passport No. Place of Issue: Expiration Date: 2. Purpose of the Trip: 0 Diplomatic, « Official, o Aid Program, o Tourist, o Business, 5 Visiting Relative, o Employment, 0 Commercial Performance, 10 Other (Please Specify). Number of Entries: Single (Embassy oversea can issue a Single Entry VISA only) 5 Normal VISA to be process within 3 working days. 0 Urgent Service with extra fee within 1 working day. Purposed Date of Entry into and Exit from Lao P.D.R. from: Date. To: Date. Port of Entry:.. 3. Your Contact Information: Name of Your Employer Address of Your Employer: Your Home Address:....... Reference in the Lao P.D.R. (Nam Address. ‘Tel /Mobile:.. I hereby declare that the information stated herein true and correct to the best of my information, knowledge and belief. Applicant’s Signature: For Official Use Only: ‘Type of VIS, Dated: