ﺳﻔﺎرة اﻟﺠﻤﻬﻮریﺔ اﻟﻴﻤﻨﻴﺔ )واﺷﻨﻄﻦ(
( اﻟﻘﻨﺼﻞ اﻟﻘﻨﺼﻠﻲ )
ATTACH Embassy of Yemen Republic
PHOTOS .Washington D.C
HERE Consular Section
( )
إﺳﺘﻤﺎرة ﻃﻠﺐ ﺗﺄﺷﻴﺮة دﺧﻮل
APPLICATION FORM FOR ENTRY VISA
:APPLICANT INFORMATION
:)اﻻﺳﻢ اﻟﻜﺎﻣﻞ واﻟﻠﻘﺐ( 1- Full name & Surname
:)اﻟﺠﻨﺴﻴﺔ( 2- Nationality :)اﻟﺠﻨﺲ( 3- Sex
:)ﻣﻜﺎن وﺗﺎریﺦ اﻟﻤﻴﻼد( 4- Place & Date of Birth
:)اﻟﺤﺎﻟﺔ اﻻﺝﺘﻤﺎﻋﻴﺔ( 5- Marital Status :)اﻟﻤﻬﻨﺔ( 6- Profession
:)رﻗﻢ ﺝﻮاز اﻟﺴﻔﺮ( 7- Passport No :)اﻟﻨﻮع( 8- Type
:)ﻣﻜﺎن وﺗﺎریﺦ ﺻﺪورﻩ( 9- Place & Date of Issue : )ﺗﺎریﺦ اﻥﺘﻬﺎء ﺻﻼﺡﻴﺘﻪ( 10- Expires on
:)أﻓﺮاد اﻷﺳﺮة اﻟﻤﺪرﺝﺔ أﺳﻤﺎﺋﻬﻢ ﺑﺎﻟﺠﻮاز( 11- Other names Shown in Passport
:)اﻟﻌﻨﻮان اﻟﺪاﺋﻢ( 12- Permanent Address
:) رﻗﻢ اﻟﻬﺎﺗﻒ ( 13- Phone Number
:)اﻟﻐﺮض ﻣﻦ اﻟﺴﻔﺮ( 14- Purpose of visit
:)ﻣﺪة اﻟﺘﺄﺷﻴﺮة اﻟﻤﻄﻠﻮﺑﺔ( 15- Duration of visa requested : )ﻋﺪد اﻟﺴﻔﺮات اﻟﻤﻄﻠﻮﺑﺔ( 16- No. of entries requested
:)ﻣﺪة اﻹﻗﺎﻣﺔ ﻓﻲ اﻟﻴﻤﻦ( 17- Period of stay in Yemen
:)اﻟﻌﻨﻮان ﻓﻲ اﻟﻴﻤﻦ( 18- Address in Yemen
:)اﻟﻤﺮﺝﻊ ﻓﻲ اﻟﻴﻤﻦ( 19- Reference in Yemen
I hereby declare that the above information is أﻗ ﺮ ﺑ ﺼﺤﺔ اﻟﺒﻴﺎﻥ ﺎت اﻟﻤﺪوﻥ ﺔ أﻋ ﻼﻩ وأﺗﻌﻬ ﺪ
accurate, and that I will fulfill and obey the laws and
.regulations of the Republic of Yemen
ﺑﺈﺡﺘﺮام ﻗﻮاﻥﻴﻦ وأﻥﻈﻤﺔ اﻟﺠﻤﻬﻮریﺔ اﻟﻴﻤﻨﻴﺔ
)اﻟﺘﻮﻗﻴﻊ( Signature )اﻟﺘﺎریﺦ( Date
OFFICIAL USE ONLY
ﻣﻨﺤﺖ ﻟﻠﻄﺎﻟﺐ ﺗﺄﺷﻴﺮة ﻣﺮور : دﺑﻠﻮﻣﺎﺳﻴﺔ / ﺧﺎﺻﺔ / ﻟﻤﻬﻤﺔ / ﻟﻠﺰیﺎرة / ﻟﻠﺴﻴﺎﺡﺔ / ﻟﻠﺘﺠﺎرة / ﻟﻠﻌﻤﻞ / ﻟﻠﺪراﺳﺔ / ﻟﻠﻤﺮاﻓﻘﺔ
ﺻﺎﻟﺢ ﻟﻐﺎیﺔ : ﺑﺘﺎریﺦ : ﺑﺮﻗﻢ:
وﻣﺪة اﻟﺒﻘﺎء ﻓﻲ اﻟﻴﻤﻦ : ﻟﻐﺮض :
أو ﻣﺠﺎﻥﺎ : رﻗﻢ ﺳﻨﺪ اﻟﺘﺤﺼﻴﻞ : واﻟﺮﺳﻢ اﻟﻤﺤﺼﻞ ﻗﺪرﻩ :
أﺳﺎس ﺻﺮف اﻟﺘﺄﺷﻴﺮة :
ﺧﺘﻢ اﻟﻘﻨﺼﻠﻴﺔ إﺳﻢ وﺗﻮﻗﻴﻊ اﻟﻘﻨﺼﻞ اﻟﻌﺎم ﺗﻮﻗﻴﻊ اﻟﻤﻮﻇﻒ اﻟﻤﺨﺘﺺ
THE FOLLOWING ATTACHEMENTS MUST BE SUBMITTED WITH THIS FORM FOR PROCESSING
)ﻣﺮﻓﻘﺎت یﺠﺐ ﺗﻘﺪیﻤﻬﺎ ﻣﻊ اﻻﺳﺘﻤﺎرة(
VALID PASSPORT ﺟﻮاز اﻟﺴﻔﺮ ﺳﺎري اﻟﻤﻔﻌﻮل
TWO (2) PASSPORT PHOTOS ﺻﻮرﺗﻴﻦ ﺷﻤﺴﻴﺘﻴﻦ ﻡﻘﺎس 46x
COPY OF RETURN TICKET or ITINERARY ﺗﺬآﺮة ﺳﻔﺮ ذهﺎب وإیﺎب
HEALTH CERTIFICATE or DOCTOR’S NOTE ﺷﻬﺎدة ﺻﺤﻴﺔ