The Embassy of The Republic of South Sudan in France/ Paris

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RADIO

MEDIA CENTER

The Embassy of

The Republic of South Sudan - France

Ministry of Interior

Directorate of Nationality, Passports and Immigration


Visa Application Form

Form 5A

(FILL OUT IN CAPITAL LETTERS ONLY)

Warning: providing false information is considered a crime in accordance with the South Sudan Nationality Act 2011 and exposes the applicant and his/her witness to legal action.

Place of Application Date: / /20

Have you Previously Applied for South Sudan Visa. Yes No

If yes, Previous visa No:. ……………………………..…. Date of Issue……………………………..….Place

of Issue……………………………..….Date of Arrival in south Sudan……………………………..….Point of

Entry……………………………..…point of Exit……………………………..….

1. Visa Type Requested: Single: Multiple: Transit: Other: (Specify)

Purpose of visit: Visit Education Tourism Medical treatment Official Other (Specify) …………………………..….

Duration of Intended Stay……………………………..….Date of Intended Arrival in South Sudan……………………………..….

Mode of Transport: Air Road/Trail River

2. Personal Details (As in Passport)

Surname: ………………………………………………………………………………………

Given Names: …………………………………………………………………………………

Date of Birth (Day/Month/Year): ……/……../……….

Place of Birth: ………………………….Country of Birth………………………….…

Sex: Male Female

Marital Status: Single Married Divorced Widowed

Nationality / Citizenship: ………………………………………………………………………………………………..

(If dual, give both)

3. Passport Details:

4. Passport Type: Regular Diplomatic Special Business Other (specify)

Passport No: …………………………Date of Issue (Day/Month/Year): ……/……/……

Country of Issue: ……………………Date of Expiry (Day/Month/Year): ……/……/………Place of Issue: ……………………………….

5. Professional / Occupation Details:

Present Occupation: .……………………….................. Title: ……………….…………………

Employer Name: ….………………………………….………………………………………….

Employer Address: …………………………………….……………………………………………………………

……………………………………………………… Phone No: ….……..……………………

E-mail: ….……..…………………………….

6. Applicant’s Contact Details:

Present Address: .……………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………….……….

Permanent Country of Origin Address: ………………………………………………………………………….………………………………………………………………………………………………………………………………………

Phone No: …………………………………………… Mobile No: . ……..…………………………….

E-mail Address: …………………………………………………………

7. Family Details:

Spouse Details

Surname: …………………………………………………………

Given Names: ……………………………………………………

Permanent Address: ………………………………………………………………………….………………………………………………………………………………………………………………………………………

Phone No: ……………………………………………Mobile No……………………………….……….

E-mail Address:. …………………………………………………………

Next of Kin Details

Surname: …………………………………………………………

Given Names: ……………………………………………………

Permanent Address: ………………………………………………………………………….………………………………………………………………………………………………………………………………………

Phone No: ……………………………………………Mobile No……………………………….……….

E-mail Address: ………………………………………………………………

8. Have you ever:

a) Been convicted of a crime or offence in any country? Yes No

b) Been deported or removed from South Sudan or any country for overstaying your visa or violating any law or regulation? Yes No

c) Been convicted and sentenced for a drug offence in any country in violation
of law concerning narcotics, marijuana, opium, stimulants or psychotropic
substances? Yes No

d) Committed trafficking in persons or incited or aided another to commit such an offence?

Yes No

e) Are you suffering from tuberculosis, any other infectious or contagious disease

Yes No

If you answer yes to any of the questions above, provide explanation below:

………………………………………………………………………….

……………………………………………………………………………….

Address of Place of Stay / Hotel: ………………………………………………………………………………….……

………………………………………………………………………………………

Funds Available For My Stay ………………………..

9. Guarantor or references in South Sudan:

Name: ……………………………………Telephone No.: ………………………………

Address………………………………………………………………………………………

Date of Birth (Day/Month/Year) : ….…../…………/……..… Sex: Male Female

Relationship to Applicant: …………………………………………………………………………………………..

Profession or occupation and position: …………………………………………………………………….

Nationality and Immigration Status: ………………………………………………………………………….

10. Declaration:

I declare that the information provided in this form is true and accurate.

Signature of the applicant (Sign below here) Date (Write below here)

………………………….………. : ….…../…………/……..…

FOR OFFICIAL USE

Approving Authority:

Officer Name: ……………………………………………. Title: ……………………………………

Entry Type: Single Multiple Period of stay …………………………………..

Officer’s Signature: ……………………………………… Date (Day/Month/Year): ….…../…………/…….….…....

Comments: ……………………………………………………………………………………………………………………………………

Fees

Amount: …………………………………………………………………..

Date of Receipt: ……………………………………… Receipt No: ……………………………….

Designated Officer’s Name: ………………………………Title: ……………………………………

Signature and stamp ………………………………………………………………

Visa Number: ……………
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