APPLICATION FOR VISA - Lao Embassy

1 PHOTOGRAPH 2 X 2 lao people 'S democratic republic PEACE INDEPENDENCE DEMOCRACY UNITY PROSPERITY Xxxxxxxxxxxxxxxxxxxxxxxx Embassy OF THE lao people S democratic republic - - APPLICATION FOR VISA --- : .. : .. FIRST NAME (IN BLOCK LETTER) FAMILY NAME -, , - : .. - - : .. DATE OF BIRTH PLACE OF BIRTH : .. : .. NATIONALITY OCCUPATION - - - : .. - - : .. PASSPORT No. PLACE OF ISSUE.

2 - - - : .. DATE OF ISSUE DATE OF EXPIRATION - : .. - : .. HOME ADDRESS TEL No.. - - - - : .. - - : .. PURPOSE OF THE TRIP MEANS OF TRANSPORTATION - - : .. - : .. DATE OF ARRIVAL IN THE LAO PDR DURATION OF STAY IN THE LAOPDR DAYS.

3 PORT OF ENTRY - : (NAME) .. (TEL): .. REFERENCE IN THE LAO PDR (ADDRESS): ..- ..- / .. - - - - : .. NEXT DESTINATION AFTER YOUR VISIT TO THE LAO PDR - : .. - - .. DATE SIGNATURE --------- - - FOR OFFICIAL USE ONLY - : .. - - : .. - - - .. Address: 2222 S Street, Washington, DC 20008; Tel: (202) 332 6416 or 667-0076; Fax: (202)332-4923 1 Lao Embassy visa