EMBASSY OF GABON

PRETORIA

No: ___________________________________

Date: _________________________________

APPLICATION FORM FOR A VISA

Family name:  
______________________________________________
First name:  
______________________________________________
Maiden name:  
______________________________________________
Date of birth:  
______________________________________________
Place of birth:  
______________________________________________
Nationality (By Birth):  
______________________________________________
Nationality (Current):  
______________________________________________
Occupation:  
______________________________________________
Employer:  
______________________________________________
Marital status:  
______________________________________________
Number of children:  
______________________________________________
Permanent Residence:  
______________________________________________

______________________________________________

______________________________________________
Temporary Residence- exact Address:  
______________________________________________
Contact number in RSA:  
______________________________________________
Military status:  
______________________________________________
Exact date of arrival in Gabon:  
______________________________________________

Type and duration of the visa applied for

Transit To:
______________________________		 Days Stopover:
____________________________________

Duration:
1 Month / 2 Month / 3 Month
Days:
__________

Passport Information

Passport Number:
______________________________		 Issuing Authority :
____________________________________

Date of Issue:
______________________________
Valid Until:
____________________________________

Detailed reasons of your travel

Detailed reasons of your travel:  
______________________________________________
Have you already lived in Gabon for longer than 3 months without interruption:  
______________________________________________
When:  
______________________________________________
Indicate precisely the names and addresses of merchants and industries you wish to meet on your business trip:  
______________________________________________
Family connections in Gabon:  
______________________________________________
Please indicate your physical address during your stay in Gabon & Tel:  
______________________________________________

______________________________________________

______________________________________________
Please indicate port of entry in Gabon:  
______________________________________________
Do you intend establishing a business or an industry in Gabon:  
______________________________________________
Where do you intend proceeding to when leaving Gabon:  
______________________________________________
Do not undertake any employment paid or unpaid, or be an au pair during your stay in Gabon or try to work permanently and to leave the Gabonese territory on the expiration of the visa granted to you.
DONE IN - DATE   SIGNATURE


__________________________		  

__________________________

Please print and complete this form and fax it to 012 342 4375