(DHA-1684) Form 21

ORDER TO ILLEGAL FOREIGNER TO DEPART FROM REPUBLIC

[Section 7(1)(g); Regulation 30(4)]

To: ...........................................................................................................................................................(name(s) and surname)

Date of birth ..................................................................................Passport No ..............................................................................................

Expiry date..................................................................................... Place of issue...........................................................................................

Residential address: .......................................................................................................................................................................................

Nationality: ................................................................................Country of origin: ........................................................................................

You are hereby notified that as an illegal foreigner in contravention of the Act, you are guilty of an offence for which you may be charged in a court of law.

However, as you have undertaken to leave the Republic voluntarily, you are hereby ordered to leave the Republic by ................................................................................ (time) on ............................../.............................. /20.............. failure of which you shall be arrested and detained pending your deportation.

Declaration by immigration officer

...........................................................................................................................................(name(s) and surname) hereby declare that I am satisfied that the holder hereof has complied with the provisions of regulation 30(4).

......................................................................                         ..............................................................                           .........................................................

Signature of immigration officer                                                         Place                                                                                                 Date

IMMIGRATION OFFICER'S PARTICULARS

Name and Surname:

.....................................................................................................................................................................................................................................

Appointment number:

.....................................................................................................................................................................................................................................

Rank/position ...............................................................................................................................................................................................................

Office: ...................................................................................... Province: ....................................................................................................................

SUPERVISOR'S PARTICULARS

Name and Surname: ......................................................................................................................................................................................................

Rank/position ................................................................................................................................................................................................................

Contact No.: Tel: ............................................................................................................................................................................................................

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge receipt of the original of this notice.

......................................................................                                  ......................................................................                               ......................................................................

Signature of illegal foreigner                                                                             Place                                                                                                            Date

Witness:

Name and surname ......................................................................           Signature: ......................................................................

CERTIFICATE BY INTERPRETER

I, ............................................................................................................................................ (name(s) and surname) of ............................................................................................................................................ (*business/residential address) with telephone number .................................................................. and cell number ...................................................................................... hereby confirm that I have mastered ................................................................................... (state language) and that I have explained to ..................................................................................................................................(name(s) and surname of foreigner) the contents of this notice in the said language and that I am satisfied that the said foreigner fully understands it.

......................................................................                      ......................................................................                             ......................................................................

Signature of interpreter                                                                       Place                                                                                                             Date

*Delete which is not applicable