‘THE REPUBLIC OF DJIBOUTI PHoTocRAPH VISA. APPLICATION Px ATTENTION: Fit hens ip CAPITAL LETTERS, ‘aur appl al pel me ora, ‘Visa can be obtained from the Embassy in Washington, DC or the Permanent Mission of Djiboutl to the United Nations in New York. ‘VISITORS ARE URGED TO OBTAIN PROPER VISAS PRIOR TO DEPARTURE. |LNAME: Fnst NAME MIDDLENAME {AST NAME SURNAME 72 DATE & PLACE OF BIRTH 3.SEX: “PERSONAL STATUS. ‘5. NATIONALITY: CURRENT NATIONALITY ES FORMER OR BIRTH NATIONALITY: 6-TYPE OF PASSPORT OR TASSPORTNO.OR TRAVEL DOCUMENT XO, | NAMEOF RSUING COUNTRY OR ‘TRAVEL DOCUMENT: homo 17. PERMANENT ADDRESS: 8.TELEPHONE: orice owe MosiLe tage ae (eg) fae : 9, PROFESSION/ OCCUPATION: 10, EMPLOYER: (NAME ADDRESS/TEL,) TI ACCOMPANYING CHILDREN12. DATE(S) OF EARLIER VISIT To DJIBOUTI 1B, PURPOSE OF TRI: 11 DURATION OF STAY: 1S. VISA REQUESTED FOR: FROM (Dsrt:woNTIIYEAR) TO. (OsTENONTILYEAR) SitEeNTRY = BOURLEENTRY < MULTILEENTRY Ve: MEANS OF SUPPORT DURING YOUR STAYIN | 17, SPONSER OR HOST IN DJIBOUTI jae ADDRESS TEL) bimourt pare ————_— SIGNATURE FOR OFFICIAL USE ONLY/ RESERVE A L’ADMINISTRATION TIREEDUVISY NOME DTOTREEDY {IS OUDECISION BES MHTORTTTS {VISA REQUIREMENTS FOR ALL. VISA APPLICANTS + Appaspor or wave dcament valid fr test 6months + 2 Viesappieatio ems duly completed (font & bck) 2 recnt pasos size color ocoraphs| Atopy ef round cet othe anerary For diplomatic end fa vis un offi! eter isroqied For business vis company Jeter eoured ‘+ Fee § 50.00 US Dollars, pustle tothe Emtussy of Ditoui or Permanent Mission of Dibut (where appli) with sey order! canpany check cash pple in persoa)~ Credit card ae personal check are NOT acco 1+ Yellow Fever Vaccination isrequzed feeling fom an infected aes, FOR RETURNING PASSPORTS: A ssiaddrested stampa envelope ora pre-pid snd complete siewsy il fr oe day delivery serve (i appa. ‘CONSULAR HOURS: Monday through Friday between 10:00 a.m. -30 pam. Passports may be collet afer 2 Business Days Applicton of potential vistors o Dioula siding inthe United States and Canada must be accompanied by noe of rues ioe their respective Embassies or Missions. ‘Vian extension is pone in Dib en case yeas ass Embassy ofthe Republic of Dibout 1156-15" soe NW, ute #515, Washing, DC 2005, Tel (2) 58 O70 F-20233 0302 E- mal basins. com ‘Permanent Mision of the Republic of Dibon tothe United Nations 46-UN Pla, Site 401, NEW Yer, NY 00171894 Tel (212) 753 3163 F 212/225 1276 Pal Dib et Page 2 of?