Dominican Republic visa form

REPUBLICA DOMINICANA~eeretaria be€.Stabobeltelaeione.s«xteriore.sDEPARTAMENTOCONSULARPhotoVISA APPLICATIONFORM1. Surname1.1 As in Passport 1.2 Others Surnames Used (Maiden, Married. etc.)2. First Name2.1 As in Passport 2.2 Other First Names Used (Maiden, Religious. Professional, Aliases. ate)3. Birth and Nationality Information3.1 Country 01 Birth 3.2 State/Province 3.3Cily34 Dale of Birth (dd/mmlyy) 3.5 First Nationality 3.6 Second Nationality4. Sex, Occupation and Proffession4.1 Sex 4.2 Proffession 4.3 Occupation5. Actual Location5.1 Country 5.2 StatelProvince5.4 Street Address5.9 Postal Code5.10 Telepllone Number 5.11 MOl/ile Telephone Number5.14 Personal E.Mail 5.15 Work E-Mail6. Passport Information6.1 Passport Number 6.2 Country of Issuance6.4 Issuing Country 6.5 Issuance Date (dd/mm/yy) 6.6 Expiration Dale (dd/mmlyy)7. Nationalldentication7.1 Country of Identification Document 7.2 Type of Document 7.3 Number 7.4 Expiration Date (dd/mmlyy)8. Marital Status8.1 Marital Status 8.2 Spouse's Full Name (Even if divorced or separaled) 8.3 Spouse's Date of Birth (dd/mmlyy10.1 Name (Hotel or Person) 10.3 Movile Telephone Number10.4 Province 10.5 City10.7 Type 01 Address 10.8 Address 10.9 Postal Code11. E d/or Sch Inf t'. ---- -- - - -- - - -- . - ._..11.1 Name 11,2 Address12. Who Will PayP For Your T" Trip?12.1 Name 12.2 RelationshipNote: Ifself payedleave blankPage 1 of 2-- -~-

13. Have You Been in The Dominican Republic Before;- Yes_ No(lf YES,answerquestionsto the right beginningwith the most recent)13.1 Date? (dd/mmlyy) 13.2 For HowLong?14. Have You Ever Been Issued a Dominican Visa?_ Yes _ No.. . -, - --.. .0.- ._.._..... .-. ---.. ........- .14.1 IssuanceDate 14.2Countryof Issuance 14.3City 14.4 Type of Visa 14.5 Visa NumberNote: You will be required to present proof of information provided above15. Visas From Other Countries:15.1 Issuing Country 15.2 Country of Issuance 15.3 Expiration Date 15.4 Type of Visa 15.5 Visa Number(dd/mmlyy)Note: You will be required to present proof of information provided above16. Has Your Dominican Visa Ever Been Cancelled or Revoked? _ Yes _ No17.3City17.4 Type of Visa18. Do You Intend to Work and/or Study in the Dominican Republic? _ Yes _ Noif YES, provide the name and address of emplover and/or school in The Dominican Republic18.1 a Type of Activity18.3a Telephone Number18.4a Province1 8.6a Street Address 18.7a Number18.1b Type 01Activity 18.2b Name (Person, School or Business)18.3b Telephone Number18.4b Province 18.6b Street Address18.7b Number19. Has Anyone Ever Filed a Visa Petition on Your Behalf? _ Yes _ Noif YES, please provide name of the person and relationshi19.1 Name (Person or Business) 19.2 Relationship20. Names and Relationships of Persons Travelin~ With You20.1 Names 20.2 RelationshipsApplicant's SignatureNumeroFechaLugarExpedienteInternal Information (Leave Blank),NumeroFechaEstatusResolucionDocumentos que acompaiian esta solicitud:Carta de Solicitud [ ]Copia Carta de Trabajo [ ]Copia de Cuenta Bancaria [ ]Copia de Pasaporte [ ]Copia de Tarjeta de Residencia [ ]Copia de visa de otros paises [ ]Copia de visas dominicanas anteriDres [ ]Copia reserva de hotel [ ]Copia reserva de vuelo [ ]Fotografia [ ]Otros [ ]Page 2 of 2