RECENT

PHOTOGRAPH
IMMIGRATION DEPARTMENT
BRUNEI DARUSSALAM

VISA APPLICATION FORM

(PLEASE COMPLETE IN BLOCK LETTERS)

Full Name : Name in Chinese Characters :

(lf Applicable)
Present Former
Nationality : Nationality (lf Applicable) :

It4arital Status : I Single lI Married Sex : n llale ] Oate of Birth : Place of Birth :

n Divorced tr Widowed [l Female l

Occupation : Home Address Religion :

Particulars of Passport/Cert. of ldentity :

Purpose of Entry :

tr Holiday fJ Business ! lnterview ! Visit Relatives n As Dependant tr Empioyment n ln Translt

Contact Address in tsrunei Darussalam :

1) lf a private visit give name, address and relationship of host.

2) if a business or professional visit give name and address of firm to be visited
3) lf for employment state the name and address of Employer.
4) lf in transit slate the country of destination,

Particulars of persons accompanying applicant and included in his/her passpo,'t i

Name in Chinese Characters

Full Name Sex Date
(lf Applicable)

Type of visa required : n Standard Single Entry n Multiple Entry I Employmerit

Has the Applicant been refused entry to or deported from any Country?
lf 'Yes', give details on a separate sheet of paper. n n No Yes
Has ihe Applicant been convicted in a Court of Law in any Country?
lf 'Yes', gi're details on a separate sheet of paper. n tr NoYes
Prcposed Length of Stay Proposed Date of Entry Date of Previous visit to Brunei
to Brunei Darussalam : Darussalam and in what capaciiy :

How much money is available tor your visit? :

(Evidence of this may be required)

Present Address :
Telephone
Number :

a) I hereby declare that all the particulars furnished by me in this application are irue.
b) | underiake noi to misuse controlied drugs or to take part in any political or other activities during my stay in Brunei Darussaiam.
c) Ifurther undertake not to be engaged in any form of employment or business without ihe written consent of the Controller of !mmigration, Brunei
Darussalam.
d) i understand that if the Controller cf lmmigration is satisfied that I or any mernber of my family breaches this underlaking or becomes an
undesirable or prohibited immigrant he will cancel my immigration pass and the passes of the members of rny family and we may be required tc
leave Brunei Darussalam within 24 hours of such cancellation.
e) Aiso, I understand that immigration siatus and period of stay to be granted are decided by the Brunei Darussalam lmrnigration authorities Lipon
my ari-ival.

flete
Signature of Applicant

This form is issued free JPKt2005

 VISA NO, : PERIOD OF STAY:

APPROVED / NOT APPFIOVED VALIDITY: VISA CATEGORY :

SINGLE I MULTIPLE

ENTRY / ENTRIES
APPROVING OFFICER : ISSUING OFFICER :

WITHIN I\4ONTHS