IMPORTANT

I, __________________________________________________________________ (surname and name of applicant), with passport number_________________________________ declare that I understand that—

For official use only

BLOK:

Office of application:

Date received:

Track & Trace Ref No.:

Submission quality checked by: ...................................

Persal number: ............................................................

Date: ...........................................................................

Regional file no.:

Passport checked/returned by: ....................................

Persal number: ............................................................

Date: ...........................................................................

Date received at Head Office:

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Fee received by: ..........................................................

Persal number: ............................................................

Receipt number: ..........................................................

Date: ............................................................................

Approved/rejected by: .......................

Persal number: ..................................

Rank: ..................................................

Conditions of visa/Reason(s) for rejection: ........................................................................

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Surname/Family name:

First name(s):

Date of birth:

Residential address in the Republic:

Home Telephone No:

Work Telephone No.

Cellphone No.

E-mail address:

Passport number:

Issuing country:

Date of issue:

Valid until:

If you have any other identity document issued by your government, provide details:

Type of document:

Number:

Date of issue:

Expiry date:

Date of entry:

Permit No:

Place of entry:

Date of expiry:

Purpose of entry:

Type of visa:

Issued at:

Reference number:

Date of issue/renewal:

Date of expiry:

* Change the status of my existing visa. (Provide details of the type of visa you require and the reason(s)); or

* Change the conditions on my existing visa as follows. (Provide details)

Provide full details of your reason(s) for requesting the above-mentioned change of status or conditions (attach page if space is not enough):

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Have you or any of your dependants accompanying you ever been convicted of any crime in any country?

Yes

No

Is a criminal/civil case pending against you or any of your dependants accompanying you in any country?

Yes

No

Are you or any of your dependants suffering from tuberculosis, any other infectious or contagious disease or any mental or physical deficiency?

Yes

No

Are you an unrehabilitated insolvent?

Yes

No

Have you ever been judicially declared incompetent?

Yes

No

Are you a member of or adherent to an association or organisation advocating the practice of social violence, or racial hatred?

Yes

No

Furnish full particulars if the reply to any of the above questions is in the affirmative:

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