Entry Clearance Form _pdf_ - SEC by pengxiang


									                                                                                                     Your Photograph must be

                                                                                                     Passport style and size

                                                                                                     Recent and true likeness
APPLICATION FORM FOR PITCAIRN ISLAND ENTRY CLEARANCE                                                 showing full face with no
THIS FORM IS PROVIDED FREE OF CHARGE                                                                 hat, helmet or sunglasses

SECTION 1. WHAT TYPE OF VISA ARE YOU APPLYING FOR?                                                   In colour taken against a
                                                                                                     plain, evenly lit and light
Long term Visitor                 Business               Extension                                   background

• Please tell us your:
2.1 Full name, as it appears in your passport. Please underline your family name.

2.2 Date of birth (dd/mm/yy)
2.3 Place of birth.
2.4 Nationality

2.5 Sex            Male                       Female
2.6a Marital status
Single          Married          Divorced              Widowed          Separated         Civil Partnership

2.6b If you selected "Civil Partnership", please confirm current status of relationship
Existing Civil Partnership        Dissolved Civil Partnership          Surviving Civil Partner (Civil Partner
2.7 What is your father’s full name?
2.8 What is your mother’s full name?
2.9 Passport number (this passport)
2.10 Issue and expiry dates
2.11 Place of issue
2.12 Is this your first passport?          Yes                No
2.13 Previous passport issue and expiry dates (dd/mm/yy)
2.14 Place previous passport was issued

• Your contact details
2.15 Your permanent home address
2.16 Your correspondence address, if different from 2.15
2.17 Home or mobile telephone number
2.18 Any home fax number
2.19 Your personal e-mail address

3.1 If you are married, in a civil partnership, or living with your unmarried partner, what is your husband’s,
wife’s, civil partner’s or unmarried partner’s name?

3.2 What is your husband’s, wife’s, civil partner’s or unmarried partner’s date of birth (dd/mm/yy)?

3.3 Where is your husband, wife, civil partner or unmarried partner now?

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3.4 What is your husband’s, wife’s, civil partner’s or unmarried partner’s nationality?
3.5 Is your husband, wife, civil partner or unmarried partner travelling with you?
Yes, on my passport               Yes, on his/her own passport                        No
3.6 Do you have any children?             Yes                 No

If you have answered yes to question 3.6, please give their details below

Full name                                  Date and Place of birth                           Nationality

Are they travelling with you          Yes, on my passport        Yes, on their passport No

4.1 Have you travelled outside your home country?            Yes                   No
4.2 Have you previously visited Pitcairn?              Yes                      No
4.3 Have you ever been refused a visa for the UK or Overseas Territories, refused entry to the UK or
Overseas Territories, or had your leave to enter or remain cancelled?       Yes              No
4.4 Have you ever been refused a visa for another country?                  Yes             No

If you have answered yes to questions 4.3 or 4.4 please complete questions 4.8 to 4.12 as applicable.
Otherwise please go to question 4.13
4.5 Where did you make your previous application?
4.6 When did you make your previous application (dd/mm/yy)?
4.7 What happened? Please give the details of any forms that were given to you
4.8 Have you ever been refused entry to, deported from, or required to leave the UK or Overseas Territories
or another country?                             Yes                       No
If yes, please give details below

4.9 Do you have any criminal convictions in any country?             Yes               No
If you have answered yes to question 4.9, please answer questions 4.10 to 4.12. If you have answered no,
please go to section 4.13
4.10 What was your conviction for?
4.11 When and where were you convicted?
4.12 What was your sentence?
4.13 Have you ever been concerned in the commission, preparation, organisation or support of acts of
terrorism, either within or outside the United Kingdom or an Overseas Territory, or have you ever been a
member of an organisation which has been involved in or advocated terrorism in furtherance of its aims?
Yes                         No
4.14 Have you ever been concerned in the commission, preparation or organisation of genocide or crimes,
including crimes against humanity and war crimes, committed in the course of armed conflict? Yes No
If you have answered yes to any of the questions, please give details below:

4.15 Are you, your husband, wife, civil partner, unmarried partner, or any dependants included in this
application, suffering from any contagious diseases of more than a short-term nature or mental disorder? If
so, please give details below:

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5.1 How long do you intend to stay on Pitcairn?
5.2 On what date do you intend to arrive & how?
5.3 Why are you going there?
5.4 What is your intended date of departure & how?
5.5 Please give details of where you will be staying during your visit, and the name and relationship of the
person (s) you will be staying with


6.1 What is your present job, and who is your employer?
6.2 When did you start this job (dd/mm/yy)?
6.3 What is your work address?
6.4 Your employer’s telephone number
6.5 Your employer’s fax number
6.6 Your employer’s e-mail address
6.7 What is your monthly income from employment?
6.8 Do you receive income from any other sources, including friends or family?     Yes           No
6.9 Do you own any assets, for example property?                  Yes               No
If you have answered yes to questions 6.8 -6.9, please give details below:

6.10 How much money is available to you for your stay?
6.11 Who is paying for your trip?

Is there any other information you wish to give about your application

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• To be completed by all applicants

The Pitcairn Island Office is processing the personal data on this form and related data for the purposes of
promoting and protecting the United Kingdom and its citizens abroad. The data may be disclosed to other
UK Government Departments, public authorities and companies assisting in the processing and production
of your visa.

You must now read the declaration below and sign it. This must be signed by the applicant personally and
not by a representative or other person acting on his/her behalf. An application for a person under the age of
18 may be completed by the parent or legal guardian.
I hereby apply for an entry clearance for Pitcairn for myself and any dependants listed in this
form. The information I have given is complete and is true to the best of my knowledge. I also declare that
the photograph(s) submitted with this form is/are a true likeness of myself and any dependants included in
the application. I confirm that if, before this application is decided, there is a material change in my
circumstances or new information relevant to this application becomes available, I will inform the Pitcairn
Island Office.
I am aware that if I have made a false statement or declaration, I may be refused leave to enter on arrival.
I declare that the information given on this form is correct to the best of my knowledge and belief.

Applicant’s signature: ________________________ Date: _______________________


Check 1 Initials                                 Check 2 Initials

ISSUE                                                 REFUSE
Authorised by
Name Date
Category Code
Effective from                                          Expiry date

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