BI-84

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PERSONAL PARTICULARS
DEPARTMENT: HOME AFFAIRs
REPUBLIC OF SOUTH AFRICA
APPLICATION FOR VISA OR TFANSIT VISA
tsectlon 7 (1) 49, read wtth socitons 1oA and 1oB:
Regulatlon a (i)l
Failure to complete this appticatjon torm in fult may resuliin th;;;;;;;;;;;j;G;;;;;;;
please use block letters and bJack ink onlv
Ern il

Period resident at this address.. . - ..... .- -
Telephone numbe(.......... ) (code)
...... (number)
Countrv of permanent residence . - .. . Period resid€nt in that country
Name, address and telephone no ol employsr, univ€rsiiy, organlsatlon' etc Io wnlcn you aI€
that you atlend or which you represent
lf self employed, state name, address, lelephone no and nalure ol business
Ivlarital status
Never
marneo
Married Separated Divorced
First narne(s) ol spouse
I\raide name
YTY II\4 IM ID ID
Date of birth
rrduu,'drLy....
NB: SEPARATE FORMS MUST BE COMPI FTFD IN RESPECT OF PERSONS OVER THE AGE OF 16
iilb'b-irtijfrln ur.idE-n inE nce or roi-nnveaiiNc oN r!!!! etlvl T::!9!I9--
Parliculars ot children endorsed on your passport accompanying youl
Surname First name(s) Date ol birth Place of birth
(1)
(2\
i3)
(4)
VISIT TO SOUTH AFRICA
Expectedate ol arrival in the R€public Y . M D "
Number ol entries required
Srngle
Multipl€
2

Proposed resideniial address (physical) in lhe Republic, including the full name(s) of your host or hotel
Names ol organlaatlons or peBona you wlll bg contactlng durlng you. stay in the Republlc:
Name Addr€ss Relationship
ldentity documeni number or permanent residence permil number ot South A{rican hosl
Indicate by medns ol an X whlchever is applicable
Have you at any lime applied tor a permit 1o settle permanonlly in South Afiica? yes no
Have you ever been restricted or refused entry into South Africa? yes no
Havo vou ever been degorted from or ordered to leave South Africa? yes no
Have you ever been convicted of any crime in any counlry? yes no
ls a criminal aclion pending against you in any country? yes no
Are you an unrehabilitated insolvenl? yes no
Are you suffering from tuberculosis or any other infectious or conlagious disease or any
mental or physical deficiency?
yes no
Have you ever been ludicrally declared ;ncompelenl? yes no
Are you a member of, or adherento an association or organisation advocating the
oractice ol social violence or racial hatred or are vou or have vou been a member of an
brganisation or associaiion ulilising crime or lerroiism to pursdo its ends?
yes no
Give paniculars it reply to one or more of the questions above is in the afiirmaiivel
To be completed by applicants applying for visitor's permlts exceeding three montha:
In the case of a spouse or dependant minor child of the holder ol a permit issued in terms ol soctions 11, 13,
14, 15, 17, 19 or 22, submission of a marriage certificate or an unabridged birth certificate.
Proof of academic sabbatical, if applicable.
Proof of non remunerative voluntarv or charitable activities to be undertaken, il applicable.
Proof of research to be undenaken, il aoolicable.
Procl of tunds available for subsistence during period ol visil.
To be completed by applicants applying for diplomatlc, oltlclEl or courteay viaaa:
In lhe case of an otficial visit, submission of a nolo verbale.
In the case of a diplomatic placing in the Republic, proof ol such placing.

To be completed only by passengers in tranaito anothsr counlry:
date and port ol departure from the Republic to that destination "" " "
'ntended
Do vou hold a visa or permit tor temporary
p€rmanenl residence in the country of your destination? (Prool
musl oe suoflnlles]
To be completed by peBons wishing to work in the R€publlc
tr tr
I SOLEMNLY DECLARE THAT THE ABOVE PABTICULARS PROVIDED BY ME ARE TRUE IN
SUBSTANCE AND IN FACT AND THAT I FULLY UNDERSTAND THE MEANING THEREOF' I FURTHER
oichnE runr r Do Nor coNTEMPLATE cHANGING THE PURPoSE oF l\'lY vlslr wHlLsr lN THE
REPUBLIC,
Signatute ot aPP cant
Date
FOR OFFICIAL USE ONLY
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