EMBASSY O F T HE R EPUBLIC O F Z AMBIA
2419 M assachusetts A venue, T elephone: ( 202) 2 65-‐9717
NW W ashington, D C 2 0008 F acsimile: ( 202) 3 32-‐0826
E-‐mail:
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VISA A PPLICATION F ORM
1. S urname:
2. F irst N ame:
Middle N ame:
3. D ate o f B irth:
Place o f B irth:
4. N ationality:
Sex:
5. P rofession:
Business T elephone N o.
6. N ationality o f P arents a t t ime o f B irth:
( )
7. P assport N o.
8. P lace o f I ssue:
D ate o f I ssue:
D ate o f E xpiration:
If a ccompanied b y y our s pouse o r c hildren, g ive t he f ollowing p articulars
9.
: ( Note: E very a pplicant f ills o ut a n i ndividual f orm)
F ull N ame ( s) D ate & P lace o f B irth R elationship
10. P resent A ddress:
T elephone N o.
( ) E mail:
11. Permanent A ddress:
T elephone N o.
( ) E mail:
12. (a) T ype o f V isa R equested: T ourist ( ) B usiness ( ) C hurch ( ) V isitor ( ) D iplomatic ( )
O fficial ( ) S tudy ( ) T ransit ( ) V olunteer ( ) C ourtesy ( )
( b) E ntry r equested: S ingle ( ) D ouble ( ) M ultiple ( )
(c) Date o f e ntry i nto Z ambia: _ _______________________________
(d) Length o f S tay i n Z ambia: _ _______________________________
13. F inal D estination o f J ourney i n Z ambia:
Full R esidential A ddress i n Z ambia:
14. Expected d ate o f D eparture f rom Z ambia:
Next D estination f rom Z ambia:
15. Duration a nd P articulars o f a ny p revious r esidence o r v isits i n Z ambia:
16. If t raveling o n b usiness, p lease l ist n ames a nd a ddresses o f p ersons t o b e v isited i n Z ambia:
17. I f v isiting r elatives o r f riends, p lease l ist n ames a nd R esidential a ddresses o f p ersons t o b e v isited i n Z ambia:
18. S ignature o f A pplicant:_______________________________________________________ D ate:__________________
For o fficial u se o nly:
Visa f ee
Rush F ee
Payment
Visa #
Receipt#
Notations
Date
Tag #
R ev. 0 4/2006