(BI-84) Form 11

EMBASSY OF THE REPUBLIC OF SOUTH AFRICA IN HANOI, VIETNAM

i s qun cng ho nam phi h nI, vit nam

Photo
3x4 cm
APPLICATION FOR VISA OR TRANSIT VISA
N XIN CP TH THC NHP CNH HOC QU CNH
[Section 7(1)(g) read with section 10A and 10B; Regulation 8(1)]
Failure to complete this application form in full may result in the visa being delayed or refused.
Please use block letters and black ink only.
Nu khng in y vo mu n, thi gian xt n ca bn s c th b ko di hoc b t chi.
Ch s dng mc en v ch in hoa.
PLEASE COMPLETE THIS FORM IN ENGLISH. ngh khai n bng ting Anh

PERSONAL PARTICULARS THNG TIN C NHN

Surname:
H
First names (in
full): Tn y
Maiden name:
Tn khc
Previous
surname(s):
H khc
Y

Date of birth:
(Ngy sinh)

City of birth: ..................

Ni sinh (thnh ph)

Country of birth:
Ni sinh (quc gia)
Gender:
Gii tnh

Male
Nam

Female
N

Nationality: ...................................
Quc tch:

If acquired by naturalisation, state original

nationality:
....................................
Quc tch gc (nu l quc tch khc)

Where and when was present nationality obtained: ...............................................

Quc tch hin ti c cp u v khi no

Passport/Travel Document Number: ..............................

Issuing authority: .................

S h chiu/Giy thng hnh

C quan cp:

Type of document: Diplomatic / Official / Ordinary Passport / Travel Document

Date of expiry: ...................

Loi h chiu: Ngoi giao / Cng v / Ph thng / Giy thng hnh

Ngy ht hn

Other (specify) .................................................

Loi khc ( ngh khai r)
Permanent residential address - a ch c tr
.
.

Period resident at this address: .

Thi gian a ch trn

Telephone number: (..........) (code)

in thoi (M)
(number) (S)

Country of permanent residence:..........

Quc gia thng tr

Period resident in that country: .

Thi gian quc gia

Occupation or profession: ..
Ngh nghip

Name, address and telephone no. of employer, university, organisation, etc. to which you are attached, or that you attend or which you
represent Tn, a ch v s in thoi ca c quan tuyn dng, trng i hc, t chc, vv.. m bn i din
...
...
...
...

If self-employed, state name, address, telephone no. and nature of business Nu lm vic t do, ngh khai tn, a ch, s in thoi v c
th cng vic ca bn
...
...
...
................................................................................................................................................................................................................................................

Marital status:
Tnh trng hn
nhn

Never
married
Cha kt
hn

Widowed
mt

Married
kt hn

Separated
Ly thn

Divorced
Ly d

First name(s) of spouse:

Tn ca chng hoc v
Maiden name:
Tn khc
Y

Date of birth:
Ngy sinh
(Nm, thng, ngy)

Nationality....................
Quc tch

NB: SEPARATE FORMS MUST BE COMPLETED IN RESPECT OF PERSONS OVER THE AGE OF 16 AND CHILDREN UNDER THE AGE OF
16 TRAVELLING ON THEIR OWN PASSPORTS.
Lu : ngi trn 16 tui v tr em di 16 tui i bng h chiu ring phi in vo mu n xin th thc ring

Particulars of children endorsed on your passport accompanying you:

Thng tin v tr em i km trong h chiu ca bn
Surname - H

First name(s) Tn

(1)
(2)
(3)
(4)

Date of birth
Ngy sinh

Place of birth
Ni sinh

VISIT TO SOUTH AFRICA thng tin v chuyn i nam phi

Expected date of arrival in the Republic: Y .... M ... D ............................................
Ngy d kin n Nam phi: (Nm, thng, ngy)
Place of arrival:..................................................
Ca khu n
Purpose of visit: ................................................
Mc ch chuyn i
Duration of stay (months, weeks or days) .............................................
Thi gian lu tr ti Nam phi (thng, tun hoc ngy)

Number of entries required S ln nhp cnh

Single
Mt
Multiple
Nhiu
Two
Hai
Proposed residential address (physical) in the Republic, including the full name(s) of your host or hotel:
a ch ni bn d nh trong thi gian Nam phi, bao gm c tn y ca ngi mi bn hoc khch sn ni bn s
.
.
.

Names of organisations or persons you will be contacting during your stay in the Republic:
Tn t chc hoc ngi bn s lin lc trong thi gian bn Nam phi

Name Tn

Address - a ch

Relationship
Mi quan h

Identity document number or permanent residence permit number of South African host:
S chng minh nhn dn hoc s giy php c tr di hn ca ngi mi bn Nam phi
.......
Indicate by means of an X whichever is applicable - nh du X vo ch thch hp

Have you at any time applied for a permit to settle permanently in South Africa?
Bn bao gi xin nh c di hn Nam phi cha?

Yes
C

No
Khng

Have you ever been restricted or refused entry into South Africa?
Bn bao gi b hn ch hoc b t chi vo Nam phi cha?

Yes
C

No
Khng

Have you ever been deported from or ordered to leave South Africa?
Bn bao gi b trc xut hoc bt buc phi ri Nam phi cha?

Yes
C

No
Khng

Have you ever been convicted of any crime in any country?

Bn bao gi b kt ti bt k quc gia no cha?

Yes
C

No
Khng

Is a criminal action pending against you in any country?

Bn c ang b ch xt x bt k quc gia no khng?

Yes
C

No
Khng

Are you an unrehabilitated insolvent?

Bn c vn rc ri v ti chnh khng?

Yes
C

No
Khng

Are you suffering from tuberculosis or any other infectious or contagious disease or any mental or
physical deficiency?
Bn c mc bn lao phi, bnh truyn nhim hoc bnh v thn kinh hoc th cht khng?

Yes
C

No
Khng

Have you ever been judicially declared incompetent?

V php lut, bn bao gi b tuyn b mt nng lc hnh vi cha?

Yes
C

No
Khng

Are you a member of, or adherent to an association or organisation advocating the practice of social

Yes
C

No
Khng

violence or racial hatred or are you or have you been a member of an organisation or association utilizing
crime or terrorism to pursue its ends?
Bn c phi l thnh vin hoc c tham gia vo t chc hoc hi c s dng bo lc x hi hoc phn bit chng
tc hoc bn tng l thnh vin hoc c tham gia vo t chc hoc hi s dng hnh ng phm ti hoc khng
b theo ui mc ch ca mnh khng?
Give particulars if reply to one or more of the questions above is in the affirmative:
Nu c cu tr li c, ngh nu chi tit:
...
..
...

To be completed by applicants applying for visitors permits exceeding three months:

Nu xin th thc Visitor qu ba thng, ngh khai mc ny
In the case of a spouse or dependant minor child of the holder of a permit issued in terms of section 11, 13, 14, 15, 17, 19 or 22, submission of a
marriage certificate or an unabridged birth certificate.
Nu l v/chng hoc con ph thuc ca ngi mang giy php c tr c cp theo cc iu khon 11,13,14,15,17,19 hoc 22, ngh np giy chng
nhn kt hn hoc giy khai sinh
Proof of academic sabbatical, if applicable - Nu ang ngh php, ngh cung cp giy t chng minh
Proof of non-remunerative voluntary or charitable activities to be undertaken, if applicable
Nu tham gia cc hot ng tnh nguyn hoc t thin, ngh cung cp giy t chng minh
Proof of research to be undertaken, if applicable - Nu i nghin cu, ngh cung cp giy t chng minh
Proof of funds available for subsistence during period of visit - Chng minh ti chnh cung cp trong thi gian Nam phi

To be completed by applicants applying for diplomatic, official or courtesy visas:

Nu xin th thc ngoi giao, cng v hoc courtesy visa
In the case of an official visit, submission of a note verbale
Nu mc ch chuyn I l cng tc, ngh np cng hm thng bo
In the case of a diplomatic placing in the Republic, proof of such placing
Nu i cng tc ngoi giao, ngh np cc giy t c lin quan

To be completed only by passengers in transit to another country Nu qu cnh Nam phi I n nc khc
Destination after leaving the Republic: ...
Quc gia n sau khi qu cnh Nam phi
Mode of travel to destination: ....
Phng tin i
Intended date and port of departure from the Republic to that destination:
Ngy v ca khu d kin ri Nam phi n quc gia
Do you hold a visa or permit for temporary or permanent residence in the country of your destination? (Proof must be submitted)
Bn c th thc hoc giy php c tr tm thi quc gia s n khng ( ngh cung cp giy t chng minh)
.

To be completed by persons wishing to work in the Republic: Yes .... No .

Nu bn mun lm vic Nam phi

Khng

If the answer is yes, please provide details: . . .

Nu cu tr li l c, ngh cung cp thm thng tin chi tit
.

I SOLEMNLY DECLARE THAT THE ABOVE PARTICULARS PROVIDED BY ME ARE TRUE IN SUBSTANCE AND IN FACT AND THAT I FULLY
UNDERSTAND THE MEANING THEREOF. I FURTHER DECLARE THAT I DO NOT CONTEMPLATE CHANGING THE PURPOSE OF MY VISIT
WHILST IN THE REPUBLIC.
TI xin cam oan rng tt c cc thng tin tI khai trn y l ng s thc v tI hon ton hiu ngha ca nhng
thng tin . TI cng xin cam oan thm rng tI s khng thay i mc ch chuyn I ca tI trong thi gian nam
phi

................

Signature of applicant

Date

Ch k ca ngi xin th thc

Ngy

FOR OFFICIAL USE

Type of visa: .............

Reasons for decision:

Dnh cho c quan nhn n

Loi th thc

L do

Approved/not approved by ... ................

...............

....................

Chp nhn/Khng chp nhn

...............

..........

on ....................................

..........

Ngy

..........