(DHA-1565) Form 5

DECLARATION BY FOREIGNER SEEKING ADMISSION

[Section 7(1)(g) read with section 9(3)(e); Regulation 6(4)]

Place of birth (town/city): ...................................... Country of birth: .............................................

Marital status: ........................................................ Nationality: .....................................................

Country of permanent residence: ...................................................................................................

Country which issued passport / travel document: ..........................................................................

Passport / travel document no ........................................ issued at (place) ................................................... on .....................................................(date) and valid until .......................................................................... (date).

Place and date of arrival in the Republic: .........................................................................................

Occupation / profession (describe in full) ........................................................................................

Purpose of visit (must be described in full and in the case of commercial activities, the nature thereof must also be described) .......................................................................................................................................

Duration of intended stay in the Republic (intended date of departure) ..........................................

Address in Republic: ........................................................................................................................

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

Have you ever been refused a visa for or admission to, deported from or instructed to leave the Republic? .................... (Yes/No). If yes, furnish details ...................................................................................................................................

I declare that the information I have furnished above is true and correct and that if I am admitted to the Republic, I will comply with the purpose and conditions of my permit.

CERTIFICATE BY INTERPRETER

I ........................................................................................................(first name and surname) of ...............................................................................................................................................(*business/residential address) hereby confirm that I have mastered .....................................................(state language) and that I have explained to ..............................................................................................(first name and surname of detainee) the contents of this notice in the said language and that I am satisfied that the said detainee fully understands it.

Signed at ..............................................on this .................day of .......................................20.........

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

Signature of interpreter