REPUBLIC OF CÔTE D’IVOIRE - amb2ci-inde.org

1 REPUBLIC OF C TE D' ivoire . APPLICATION FOR A SHORT - STAY VISA. PHOTO. This application form is free 1. Surname (s) (family name(s)) FOR EMBASSY/. CONSULATE USE ONLY. 2. Maiden name (if applicable) Date application: 3. First names 4. Date of birth (day-month-year) 5. ID-number File handled by: 6. Place and country of birth Supporting documents: Valid passport 7. Current nationality /ies 8. Original nationality (nationality at birth) Company's letter Invitation letter 9. Sex 10. Marital status: Air ticket Male Female Single Married Separated Yellow fever certificate Divorced Widow (er) Other 11. Type of passprt: Other National passport Diplomatic passport Service passport Travel document Alien's passport Seaman's passport Other travel document (please specify): 12.

2 Passport number 13. Issued by 14. Date of issue until 16. Current occupation Visa: 17. Employer and employer's address and telephone number. For students, name and adress of college/univ Refused Granted 18. Main destination 19. Type of visa: 20. Visa: Airport transit Individual Number of entries Transit Short stay Collective 1. 2. 21. Number of entries requested 22. Duration of stay (maximum 3 months) Multiple Single entry Two entries Multiple entries Visa is requested for: days 23. Dates of previous visit to C te d' ivoire Valid from To 24. In the case of transit, have you an entry permit for the final country of destination? No Yes , valid until: Issuing authority: Valid for: 25.

3 Purpose of travel Tourism Business Cultural/Sports Official Visit to family or Friends Other (please specify): ATTENTION: Fill out all heading using CAPITAL LETTERS, Your application shall not be processed in case of error or ommission 26. Date of arrival 27. Date of departure FOR EMBASSY/. CONSULATE USE ONLY. 28. Border of first entry or transit route 29. Means of transport 30. Name of host or company in Cote d' ivoire and contact person in host company. If not applicable, give name of hotel or temporary address in the Cote d' ivoire Name Telephone and telefax Full address address 31. Who is paying for your cost of travelling and for your costs of living during your stay?

4 Myself Host person/s Host compagny (State who and how and present corresponding documentation 32. Spouse's name 33. Spouse's date and place of birth 34. Children (Applications must be submitted separately for each passport). Name First name Date of birth 1. 2. 3. 35. clause I hearby pledge to accept no paid or any employment during my stay in C te d' ivoire , to make no attempt to remain in the country indefinitely and leave Ivorian territory upon expiry of the visa which may be granted to me. My signature commits my responsibility and, in case of misrepresentation, makes me liable to prosecution as provided by law as well as to refusal of visa in future.)

5 36. Applicant's home address 37. Telephone number 38. Place and date 39. Signature (for minors, signature of custodian/. guardian).