EMBASSY OF THE BOLIVARIAN
REPUBLIC OF VENEZUELA
GEORGETOWN-GUYANA
CONSULAR SECTION
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VISA APPLICATION
PERSONAL INFORMATION
NAME: _________________________SURNAME: ______________________________
NATIONALITY: ______________________MARITAL STATUS: (S)___(M)___(W)___(D)___
PLACE OF BIRTH: COUNTRY:_______________________________________________
STATE:________________________CITY:_____________________
DATE OF BIRTH:__________________________________SEX: (M)_______(F)________
HOME ADDRESS: ________________________________________________________
______________________________________TELEPHONE Nº:____________________
NAME OF EMPLOYER:_____________________________________________________________
EMPLOYER’S ADDRESS:______________________________________________________________
EMPLOYER’S TELEPHONE Nº:______________________________________________
OCUPATION:_____________________________________________________________
PASSPORT INFORMATION
PASSPORT Nº:__________________________ TYPE: REGULAR__________
DIPLOMATIC________
OTHERS____________
DATE OF ISSUE_______________________PLACE OF ISSUE:____________________
DATE OF EXPIRATION:____________________________________________________
REGISTRATION / I.D. CARD Nº:______________________________________________
TRIP INFORMATION
PURPOSE______________________________________________________________
LENGTH OF STAY IN VENEZUELA:___________________________________________
COMPANY/ PERSON TO BE CONTACTED IN VENEZUELA:________________________
______________________________________________________________________
ENTRANCE DATE:_________________________EXIT DATE:______________________
AIRLINE_________________________________FLIGHT Nº:______________________
WHO IS RESPONSIBLE FOR YOUR TRIP EXPENSES?
_______________________________________________________________________
OFFICIAL DEPARTMENT REQUESTING THE VISA:
_______________________________________________________________________
ADDRESS IN VENEZUELA_____________________________________________________________
________________________________________TELEPHONE_____________________
OTHER ADDRESS THAT YOU WISH TO GIVE IN CASE OF AN EMERGENCY:
_______________________________________________________________________
OTHER INFORMATION
HAVE YOU BEEN TO VENEZUELA BEFORE?: YES____________NO____________
IF YES, STATE THE DATE:__________________________________________________
HAVE YOU REQUESTED VISA TO VENEZUELA BEFORE?: YES_________NO________
IF YES, STATE WHEN AND WHERE:__________________________________________
KIND OF VISA:_______________________________
……………….………………………..…
SIGNATURE OF THE APPLICANT
PLACE DATE
PLEASE DO NOT WRITE IN THIS SPACE
INFORMATION OF THE VISA GRANTED:
Actuación Nº: -----------------------------------------------------DATE-------------------------------------------------------
CLASIFICATION---------------------------------------------------DURATION----------------------------------------------
AUTHORIZATION BY MRE: ------------------------------------------------------------------------------------------------
DATE: -----------------------------------------
AUTHORIZATION BY DIEX: RIIE-1- ------------------------------------------------------------------------------------
DATE: ------------------------------------------
AUTHORIZED BY: ----------------------------------------------CHECKED BY: ----------------------------------------
ORSERVATIONS ---------------------------------------------------------------------------------------------------------------
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