Form EE-10/2004 "Ethiopia Visa Application Form - Embassy of Ethiopia" - Greater London, United Kingdom

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F
EE-10/2004
ORM
17 P
G
T
: 020 7589 7212
RINCES
ATE
EL
E
E
, L
MBASSY OF
THIOPIA
ONDON
L
7 1
F
: 020 7584 7054
ONDON SW
PZ
AX
C
O
ONSULAR
FFICE
www.ethioembassy.org.uk
P
& V
S
ASSPORT
ISA
ERVICES
-
: i n f o @ e t h i o e m b . o r g . u k
E
M A I L
V
A
F
ISA
PPLICATION
ORM
.
PLEASE TYPE OR PRINT YOUR ANSWER IN THE SPACE PROVIDED BELOW EACH ITEM
USE BLACK OR BLUE INK ONLY
1.
2.
3.
GIVEN NAMES
TITLE
SURNAME
4.
5.
/
HOME ADDRESS
CITY
TOW N
6.
7.
8.
COUNTY
POSTAL CODE
COUNTRY
9.
.
10.
.
11. F
12.
-
DAYTIME TELEPHONE NO
EVENING TELEPHONE NO
AX NUMBER
E
MAIL ADDRESS
13.
14.
/
OCCUPATION
SPECIFIC FIELD OF STUDY
BUSINESS
15.
16.
(
/
/
)
17.
/
18.
NATIONALITY
DATE OF BIRTH
DD
MM
YY
CITY
TOW N OF BIRTH
COUNTRY OF BIRTH
19.
(
,
)
PURPOSE OF VISIT
IF OTHER
PLEASE STATE PURPOSE
…………......................................................
TOURIST
BUSINESS
TRANSIT
DIPLOMATIC
OFFICIAL
OTHER
20.
21.
TYPE OF ENTRY
DOCUMENT TYPE
SINGLE
D O U B L E
M U L T I P L E
PASSPORT
TRAVEL DOCUMENT
( T R A N S I T O N L Y )
( E X C L U D E S T R A N S I T )
22.
23.
DOCUMENT NUMBER
DATE OF ISSUE
DO NOT WRITE IN THIS SPACE
FOR OFFICIAL USE ONLY
24.
25.
26.
COUNTRY OF ISSUE
CITY OF ISSUE
DATE OF EXPIRY
27.
(
)
28.
29.
VISA NUMBER
ENTRY
DATE OF DEPARTURE
LENGTH OF STAY
IN DAYS
DATE OF
30.
?
W HERE DO YOU PLAN TO STAY
:
ADDRESS
ISSUE DATE
31.
:
32.
.:
CONTACT NAME
TELEPHONE NO
33.
?
34.
,
HAVE YOU BEEN TO ETHIOPIA BEFORE
IF YES
HOW LONG DID YOU
VALID UNTIL
?
YES
NO
STAY
:
:
FROM
TO
35.
,
?
IF YES
W HERE DID YOU STAY
GRATIS
:
ADDRESS
YES
NO
36.
:
3 7 .
TELEPHONE NO.:
FEE PAID
CONTACT NAME
38.
?
W HAT W AS THE PURPOSE OF THE VISIT
TOURIST
BUSINESS
TRANSIT
DIPLOMATIC
OFFICIAL
OTHER
.
RECEIPT NO
EMPLOYER OR SCHOOL INFORMATION
39.
40.
.
EMPLOYER OR SCHOOL NAME
EMPLOYER OR SCHOOL TEL
41.
EMPLOYER OR SCHOOL ADDRESS
P H O T O G R A P H
42. CHILDREN / DEPENDENTS ON THE SAME PASSPORT
A t t a c h o n e p h o t o g r a p h
SURNAME
GIVEN NAMES
SEX
DATE OF
PLACE OF
w i t h y o u r n a m e w r i t t e n
BIRTH
BIRTH
i n C A P I T A L S o n t h e
(DD/MM/YY)
b a c k .
I
.
CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOW LEDGE AND BELIEF
A
:
D
:
P P L I C A N T S S I G N A T U R E
A T E
If a travel agency or another person on your behalf has prepared this application, they should indicate the name and address of the agency or person with the
appropriate signature of the individual preparing the form.
S
:
D
:
I G N A T U R E O F P E R S O N P R E P A R I N G F O R M
A T E
F
EE-10/2004
ORM
17 P
G
T
: 020 7589 7212
RINCES
ATE
EL
E
E
, L
MBASSY OF
THIOPIA
ONDON
L
7 1
F
: 020 7584 7054
ONDON SW
PZ
AX
C
O
ONSULAR
FFICE
www.ethioembassy.org.uk
P
& V
S
ASSPORT
ISA
ERVICES
-
: i n f o @ e t h i o e m b . o r g . u k
E
M A I L
V
A
F
ISA
PPLICATION
ORM
.
PLEASE TYPE OR PRINT YOUR ANSWER IN THE SPACE PROVIDED BELOW EACH ITEM
USE BLACK OR BLUE INK ONLY
1.
2.
3.
GIVEN NAMES
TITLE
SURNAME
4.
5.
/
HOME ADDRESS
CITY
TOW N
6.
7.
8.
COUNTY
POSTAL CODE
COUNTRY
9.
.
10.
.
11. F
12.
-
DAYTIME TELEPHONE NO
EVENING TELEPHONE NO
AX NUMBER
E
MAIL ADDRESS
13.
14.
/
OCCUPATION
SPECIFIC FIELD OF STUDY
BUSINESS
15.
16.
(
/
/
)
17.
/
18.
NATIONALITY
DATE OF BIRTH
DD
MM
YY
CITY
TOW N OF BIRTH
COUNTRY OF BIRTH
19.
(
,
)
PURPOSE OF VISIT
IF OTHER
PLEASE STATE PURPOSE
…………......................................................
TOURIST
BUSINESS
TRANSIT
DIPLOMATIC
OFFICIAL
OTHER
20.
21.
TYPE OF ENTRY
DOCUMENT TYPE
SINGLE
D O U B L E
M U L T I P L E
PASSPORT
TRAVEL DOCUMENT
( T R A N S I T O N L Y )
( E X C L U D E S T R A N S I T )
22.
23.
DOCUMENT NUMBER
DATE OF ISSUE
DO NOT WRITE IN THIS SPACE
FOR OFFICIAL USE ONLY
24.
25.
26.
COUNTRY OF ISSUE
CITY OF ISSUE
DATE OF EXPIRY
27.
(
)
28.
29.
VISA NUMBER
ENTRY
DATE OF DEPARTURE
LENGTH OF STAY
IN DAYS
DATE OF
30.
?
W HERE DO YOU PLAN TO STAY
:
ADDRESS
ISSUE DATE
31.
:
32.
.:
CONTACT NAME
TELEPHONE NO
33.
?
34.
,
HAVE YOU BEEN TO ETHIOPIA BEFORE
IF YES
HOW LONG DID YOU
VALID UNTIL
?
YES
NO
STAY
:
:
FROM
TO
35.
,
?
IF YES
W HERE DID YOU STAY
GRATIS
:
ADDRESS
YES
NO
36.
:
3 7 .
TELEPHONE NO.:
FEE PAID
CONTACT NAME
38.
?
W HAT W AS THE PURPOSE OF THE VISIT
TOURIST
BUSINESS
TRANSIT
DIPLOMATIC
OFFICIAL
OTHER
.
RECEIPT NO
EMPLOYER OR SCHOOL INFORMATION
39.
40.
.
EMPLOYER OR SCHOOL NAME
EMPLOYER OR SCHOOL TEL
41.
EMPLOYER OR SCHOOL ADDRESS
P H O T O G R A P H
42. CHILDREN / DEPENDENTS ON THE SAME PASSPORT
A t t a c h o n e p h o t o g r a p h
SURNAME
GIVEN NAMES
SEX
DATE OF
PLACE OF
w i t h y o u r n a m e w r i t t e n
BIRTH
BIRTH
i n C A P I T A L S o n t h e
(DD/MM/YY)
b a c k .
I
.
CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOW LEDGE AND BELIEF
A
:
D
:
P P L I C A N T S S I G N A T U R E
A T E
If a travel agency or another person on your behalf has prepared this application, they should indicate the name and address of the agency or person with the
appropriate signature of the individual preparing the form.
S
:
D
:
I G N A T U R E O F P E R S O N P R E P A R I N G F O R M
A T E
Visa Application Form

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