REPÚBLICA FEDERATIVA DO BRASIL Protocol number Visa number

MINISTÉRIO DAS RELAÇÕES EXTERIORES

CONSULADO-GERAL EM LAGOS

VISA APPLICATION FORM

IMPORTANT: FORMS THAT ARE INCOMPLETE AND/OR INCORRECTLY FILLED OUT WILL BE RETURNED.
INSTRUCTIONS
 Write in block letters
 Complete the first and second page, except for the box marked “For Official Use Only”.
 Answer all questions thoroughly and accurately. If a question does not apply, please write N/A.
 Sign the form.
CAREFULLY READ AND FOLLOW THE INSTRUCTIONS BELOW.

01 - Full name (First / Middle / Family Name)

KENEGBE GODFREY TEGA Attach photo here
02 - Place of birth (city/state/country) 03 - Date of birth - size: 40 mm x 35mm
Day Month Year
ORIA ABRAKA DELTA STATE NIGERIA 07 05 2001
04 - Country of citizenship 05 - Sex 06 - Marital status - white background
NIGERIA Male Female SINGLE

07 - Passport # 08 - The issuing country 09 - Expiration date - front view, full face
Day Month Year
A12606026 NIGERIA 07 07 2027 - must be a recent
picture
10 - Parents’ full name
Father_____________________KENEGBE ANDREW______________________________________________
Mother_________________ KENEGBE ROSE_____________________________________________________ --

11 - Job position
N/A
12 - Employer
UNEMPLOYED
13 – E-mail kenegbe50@gmail.com
14 - Business address 15 - Business telephone # / Mobile
07032611367
N/A

16 - Home address 17 - Home telephone # / Mobile

07032611367
NO 33, ORIA ABRAKA, DELTA STATE, NIGERIA

FOR OFFICIAL USE ONLY

A - Consulta à SERE B - Autorização da SERE C - Tipo do Visto

OF  TEL  No. _______ DESPTEL No. ______

D -  Concessão E -  Uma entrada F - Validade G - Data de emissão do visto
 Denegação  Múltiplas entradas ________anos/dias ______/______/______
H - Observações I - Data de apresentação do pedido Assinaturas

______/______/______
Funcionário Chefia

18 – PURPOSE OF TRIP

TOURISM OFFICIAL GOVERNMENT MISSION

BUSINESS TAKE PART IN SCIENTIFIC OR CULTURAL PROGRAM

ATTEND SEMINAR OR CONFERENCE RESEARCH ACTIVITIES

VISIT AN EXHIBITION OR TRADE FAIR TRANSIT TO ANOTHER COUNTRY

RELIGIOUS MISSION WORK PERMIT

PARTICIPATE IN A SPORT OR ARTISTIC ACTIVITY PERMANENT RESIDENCE VISA

ATTEND SCHOOL O OTHER

19 - FULL DETAILS OF PURPOSE OF TRIP (MANDATORY):

Touring in Brazil has been on my bucket list since I was a Kid, Pele has been my inspiration ever since, going to his
Museum (The Pele Museum) in Santos would be a great experience and achievement for me
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

20 – Place of arrival in Brazil 21 – Intended date of arrival 22 – Final destination in Brazil 23- Intended Length of Stay

GUARULHOS AIRPORT, SAO NOVEMER 25 SAO PAULO 2 MONTHS

PAULO

24 – Contact Person in Brazil (name, institution, and phone)

KAMILLA MISAEL MARQUES, LAWYER, OAB/SP 459.941, +55 1196-099-0872

25 - Full address and phone number in Brazil where you will be staying

RUA JOAO DE SIQUEIRA AFONSO 422, +55-1196-099-0872

26 - Have you ever been to Brazil? 27 - If Yes for item 26, provide the date, place, and duration of the last visit
N/A
Yes No
28 - I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE (to be signed by the applicant)

Name Signature
KENEGBE GODFREY TEGA