1
2Annex 2
MINISTRY OF FOREIGN AFFAIRS OF THE REPUBLIC OF TAJIKISTAN
to the Governmental Decree of
the Republic of Tajikistan
VISA APPLICATION FORM
#122 from 27.02.2009
Fill out the application form with capital letters (marked with black type)
1. Passport number
2. Place of issue: country
City (town)
District
3. Citizenship
4. Date of issue
5. Date of Expire
Place for color photo
6. Surname (Last name)
Size 3x4 cm
7. First name
8. Middle (other) name
9. Date of Birth
10. Place of Birth: District
City (town)
Country
11.Nationality
12. Sex
13. Marital status:
Married
Single
Male
Female
Divorced
14. Permanent address (country, city (town), street, house or apartment`s number, zip code):
15. Telephone number: Office
Fax:
Mobile:
E-mail address:
16. Name and address your office, institution or type of activity: Name
Address:
17. Position (if you are a student write “student” if retired, write “retried”). Describe your work (activity):
18. Date of arrival to Tajikistan
19. Date of departure from Tajikistan.
20. Number of entries: (single, double, multiple,
(for extension of visa, indicate the duration of
exit visa)
stay)
21. PURPOSE OF VISIT (the category of visa will be identified according to the purpose of visit; therefore, indicate the exact and complete purpose of your visit).
22. Place of stay in the Republic of Tajikistan (name and full address of the hotel. If it is a diplomatic representation, private house, state agency or other place, indicate
the full address):
23. Telephone number of the
place of your stay: Office:
Fax:
Mobile:
E-mail address:
24. Who will pay for your trip (is case of need, consular officer may request
25. Have you visited Tajikistan previously? Date and duration of your previous stay
prove of availability of funds, necessary to stay in the Republic of Tajikistan)
in the Republic of Tajikistan?
26. Ha
ve
you ever been issued a Tajik visa
? If
«YES»:
When:
Where:
What type (category):
For how long:
Annex 2
MINISTRY OF FOREIGN AFFAIRS OF THE REPUBLIC OF TAJIKISTAN
to the Governmental Decree of
the Republic of Tajikistan
VISA APPLICATION FORM
#122 from 27.02.2009
Fill out the application form with capital letters (marked with black type)
1. Passport number
2. Place of issue: country
City (town)
District
3. Citizenship
4. Date of issue
5. Date of Expire
Place for color photo
6. Surname (Last name)
Size 3x4 cm
7. First name
8. Middle (other) name
9. Date of Birth
10. Place of Birth: District
City (town)
Country
11.Nationality
12. Sex
13. Marital status:
Married
Single
Male
Female
Divorced
14. Permanent address (country, city (town), street, house or apartment`s number, zip code):
15. Telephone number: Office
Fax:
Mobile:
E-mail address:
16. Name and address your office, institution or type of activity: Name
Address:
17. Position (if you are a student write “student” if retired, write “retried”). Describe your work (activity):
18. Date of arrival to Tajikistan
19. Date of departure from Tajikistan.
20. Number of entries: (single, double, multiple,
(for extension of visa, indicate the duration of
exit visa)
stay)
21. PURPOSE OF VISIT (the category of visa will be identified according to the purpose of visit; therefore, indicate the exact and complete purpose of your visit).
22. Place of stay in the Republic of Tajikistan (name and full address of the hotel. If it is a diplomatic representation, private house, state agency or other place, indicate
the full address):
23. Telephone number of the
place of your stay: Office:
Fax:
Mobile:
E-mail address:
24. Who will pay for your trip (is case of need, consular officer may request
25. Have you visited Tajikistan previously? Date and duration of your previous stay
prove of availability of funds, necessary to stay in the Republic of Tajikistan)
in the Republic of Tajikistan?
26. Ha
ve
you ever been issued a Tajik visa
? If
«YES»:
When:
Where:
What type (category):
For how long:
27. Ha
ve
you ever been refused a visa? If «YES»:
When:
Where:
What was you purpose of visit:
For how long requested:
28. Do you intend to work in Tajikistan? If «YES», indicate name and address of
29. Do you intend to study in Tajikistan? If «YES», indicate name and address of
employer:
the Institution or University:
30. Please indicate the information about your relatives in the Republic of Tajikistan (father, mother, sister/brother, children, adopted children, spouse, fiancée
etc):
31. IMPORTANT: AFTER HAVING READ THE LISTED BELOW QUESTIONS ATTENTIVELY, PLEASE MARK THE “YES” OR “NO”:
- have you ever been arrested or convicted for any offence of crime within the
YES
NO
territory of the Republic of Tajikistan? If answer «YES», please describe it in
the separate page
- have you ever been a member of terrorist or extremist group or organization,
human trafficking, weapons and ammunition, illegal drug trafficking and their
YES
NO
precursors, illegal immigration?
- do you have a criminal record for felony in the territory of the Republic of
YES
NO
Tajikistan or in any other foreign country?
- have you ever been subject of pardon or amnesty?
YES
NO
- did you or do you have infections (contagious) of diseases harmful for the
YES
NO
health surrounding society?
32. Was this application prepared by another person (organization)? If «YES», then:
YES
NO
The inviting side is informed that according to the legislation of the Republic of Tajikistan, bears responsibility for authenticity of data indicated in the application as well as for the timely preparation
of the documents of the invited foreign citizen for the right of: stay in the Republic of Tajikistan, movement within the territory and for exit from the Republic of Tajikistan upon expiring their defined
term of stay.
who:
relation with applicant:
full address and telephone number:
date and signature (organization putting a
stamp):
33.
I, hereby certify that after having read the questions listed in the application, I acknowledged the full responsibility for my answers. I am well aware that the false or misleading statement may result
in their permanent refusal of a visa. I understood that possession of a visa does not automatically entitle the bearer to enter the Republic of Tajikistan upon arrival at a point of entry.
Applicant`s signature _________________________________________________
Date _______________________________________________________________
Барои истифодаи хизматї
Аз љониби корманди консулї пур карда мешавад
Раводиди тањти раќами
Категорияи (ба таври пурра)
Ба мўњлати (аз кай то кай)
Аз љониби (ному насаб, имзо
ва мўњри Консул)
Санаи судури раводид
