South Africa Visa (Sticker Visa)

Surname *
First names (in full)
Maiden name *
Previous surname(s) *
Date of birth *
Month and year of birth
Place of birth
Country of birth
Gender (write in full)
Nationality
Passport/Travel Document Number
Issuing authority
Type of document: Diplomatic/Official/Ordinary Passport/Travel document/other (specify)
Permanent residential address in country of normal residence
Period resident at this address:
Country of permanent residence:
Telephone number:
Home telephone No:
E-mail address:
Period resident in that country:
Occupation or profession:
Name of Employer:
Telephone No:
E-mail address:
If self-employed, state name, address, telephone no. and nature of business:
Address:
Telephone No:
Marital status: Never married, Married, Widowed, Separated, Divorced
First name(s) of spouse:
Maiden name:
Date and place of marriage:
Date of birth of spouse:
Nationality:
Expected date of arrival in the Republic:
Duration of stay (months, weeks or days):
Place of arrival:
Purpose of visit:
Number of entries required: Single, Two, Multiple
Name of Host or Hotel:
Telephone of Host or Hotel:
Names of Organizations or persons you will be contacting during your stay in the Republic:
Relationship:
Have you at any time applied for a permit to settle permanently in the Republic?

Yes

No

Have you ever been restricted or refused entry into the Republic?

Yes

No

Have you ever been deported from or ordered to leave the Republic?

Yes

No

Have you ever been convicted of any crime in any country?

Yes

No

Is a criminal action pending against you in any country?

Yes

No

Are you an unrehabilitated insolvent?

Yes

No

Are you suffering from tuberculosis or any other infectious or contagious disease or any mental or physical deficiency?

Yes

No

Have you ever been judicially declared incompetent?

Yes

No

Are you a member of, or adherent to an association or organization advocating the practice of social violence or racial hatred?

Yes

No

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