EMBASSY OF IRELAND,

11 NEGRO CRESCENT
MAITAMA DISTRICT, ABUJA
VISA TEL: 09 4620612
FAX: 09 4620613
EMAIL: abujaembassy@dfa.ie
www.embassyofireland.org.ng

Questionnaire
to Accompany all Visa Applications

NOTE: Before completing this form please read the Visa Requirements on
the Irish Immigration authorities’ website www.inis.gov.ie

Important Information about This Form

• This questionnaire should be fully completed, in English or Irish. Please

include all pages of the questionnaire with your application

• All information given in this questionnaire must be true and correct.

False information or fraudulent documentation provided with your
application, or with any accompanying application, will result in your
application being refused. No appeal will be allowed and no visa will be
granted for at least five years.

• The declaration must be completed and signed personally by you, the

applicant. (Except in the case of a child under 16, whereby the parent(s)
may sign on behalf of child).

• This Questionnaire must be submitted along with your Visa Application

Form

1
 1. Personal Details
Name as in Passport: _____________________________________________

Is this your 1st Passport Yes___ No___

(If no, please submit copy of any previous passport held)

Gender: Male___ Female___

Marital Status: Single___ Married ___Divorced___ Widowed___

Spouses Name: _____________________ Date of Birth: _____________________

Other spouse if applicable: _____________________________________________

Spouses Current Address: __________________________________________

_________________________________________
_________________________________________
_________________________________________
(Please give addresses for all spouses)

Father's Name: _______________ Mother's Name:___________________

Children:
Name Date of Birth Nationality Name of other
parent

(Please include details of all children including those from previous relationship)

Details of any other dependants:

Name Date of Birth Nationality Reason they are
your dependent

2
 Immigration and Travel History

Have you ever applied for a visa for any other country? Yes___ No___

If yes please give details:

Countries: Date : Was this visa granted?

__________________ ______ Yes ___ No ___
__________________ ______ Yes ___ No ___
__________________ ______ Yes ___ No ___
__________________ ______ Yes ___ No ___
__________________ ______ Yes ___ No ___
__________________ ______ Yes ___ No ___

If you have been refused a visa, you must submit original letter of refusal

NOTE: Failure to mention previous visa refusals for Ireland or any other country
may result in your current application being refused.

Assistance

Did you receive assistance from any other person in completing this application?
Yes __ NO__

Details of persons giving assistance:

Name: ____________________________________________________

Relationship to applicant______________________________________

For person providing assistance

Have you put all questions in this questionnaire and the application form to the
applicant in person to ensure the answers are correct? Yes____ No____

Signature of assistant ____________________________________________

3
 Declaration

· I understand that an Irish visa does not give me permission to enter the United
Kingdom, including Northern Ireland, or any other state without first obtaining
the necessary visas from the relevant authorities.

· I agree to observe the conditions of my visa, and to depart from Ireland in

accordance with these conditions

· I declare that all documentation I am submitting with my application is

authentic and does not contain any false information.

· A notarised translation is included for any document which is not in the English
or Irish languages.

· I understand that any breach of these conditions may lead to refusal of my visa
application, refusal of permission to enter the state or subsequent removal from
the state.

- I understand that if I submit any false or misleading information or documents

(or if any application submitted with my application contains any false or
misleading information or documents) my application will be refused without the
right of appeal and no further Irish visas will be granted for at least five years.

I give my permission for the Irish authorities to share my details with other EU
states, including the United Kingdom with which there is a common border, in
relation to immigration matters. I also give my permission to any other EU state
to share any information it holds pertaining to me in relation to immigration
matters with the Irish authorities.

I hereby apply for a visa to Ireland. In signing this declaration I am undertaking

that:

· I understand the questions and contents of this form.

· The information I have given is true and correct.

· I will observe the conditions of my visa.

Signed: Dated: