BI-84

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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.
Page 1: at{4 PERSONAL PARTICULARS DEPARTMEN

BI-84

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