ࡱ> molq` bjbjqPqP 8l::$ ('''''''$(hZ+h'ooo''###o'#o'##:#, $ HDC""# I$<'0(# +e"+ $+ $@W^#Ln'' # (oooo$ RPUBLIQUE DE MADAGASCAR Tanindrazana Fahafahana Fandrosoana AMBASSADE DE MADAGASCAR Avenue de Tervueren 276 1150 Bruxelles Tl.: 02/770.17.26 / 74 Fax: 02/772.37.31 DEMANDE POUR UN VISA DE MOINS DE TROIS MOIS (Application form for Visa less than THREE months) NOM: (Name)NOM DE JEUNE FILLE: (Maiden name)PRENOMS: (First and middle names) N(E) LE: (Date of birth)A: (Place of birth City or Town, State or District, Country)NATIONALIT ACTUELLE: (Present nationality)NATIONALIT DORIGINE: (Previous nationality) TEL / GSM:SITUATION DE FAMILLE: (Family status) Photo didentit (Photograph)DOMICILE HABITUEL: (Home address)RSIDANT ACTUELLEMENT : (Present address)PROFESSION OU QUALITɠ: (Occupation or Title) PASSEPORT N: (Passeport n) EMPLACEMENT RESERV LADMINISTRATION (For official use only) Visa N: ............................................................. Date of issue: ...................................................... Period of use: ...................................................... Authorised lenght of stay: .................................... Authorised number of entries: .............................. Authorisation reference: .......................................DELIVR LE: (Date of issue)PAR: (Issued by)VALABLE JUSQUAU: (Valid until)TRANSIT A DESTINATION DE: (Transit and Country to which proceeding)ALLER SIMPLE AVEC ARRT DE: JOURS (One way with stopover for days)ALLER-RETOUR AVEC ARRT DE: JOURS (Round-trip with stopover for days)COURT SEJOUR DE: JOURS (Short stay for days)VALABLE DU: AU: (Valid from) (To)NOMBRE DENTREES: (Number of entries) ETES VOUS ACCOMPAGNE DURANT VOTRE VOYAGE? SI OUI, INDIQUEZ LES NOMS ET PRENOMS. Do you travel alone or with relatives? If YES, give names)MOTIFS DU VOYAGE (Indispensable!): (Specify reasons of your trip)TSVP SIL SAGIT DUN VOYAGE DAFFAIRES, INDIQUEZ LES NOMS ET ADRESSES DES CORRESPONDANTS OU INDUSTRIELS QUE VOUS DSIREZ RENCONTRER: (If you are traveling on business, please give names and addresses of correspondents or businessmen you wish to contact). SIL SAGIT DUNE PARTICIPATION A UN CONGRS OU A UNE MANIFESTATION, INDIQUEZ LORGANISATEUR, LE LIEU, LA DATE, LA DURE. (Should you have to attend a congress or meeting, give the name of the organizing party, the place, the date and the length of the meeting) SIL SAGIT DTUDES UNIVERSITAIRES OU STAGES TECHNIQUES, INDIQUEZ LES TABLISSEMENTS FRQUENTS, LIEUX, DATES ET DURE. (if you intend to take up a study or technical training, give names of Institutions to be attended, places, dates and length) AVEZ-VOUS DJ HABIT MADAGASCAR PENDANT PLUS DE TROIS MOIS SANS INTERRUPTION? (Have you ever lived in Madagascar for over three consecutive months?)PRCISEZ A QUELLE DATE ET O٠? (Give date and place)RFRENCES DANS LE PAYS DE RSIDENCE - NOMS ET ADRESSES EXACTES( contacter en cas durgence) : (References from your country names and exact addresses, in case of emergency) ATTACHES FAMILIALES OU RFRENCES A MADAGASCAR: (Relatives or references in Madagascar) INDICATION PRCISE DES LIEU ET DATE: (Specify place and date of)DENTRE A MADAGASCAR: (entry in Madagascar) DE SORTIE DE MADAGASCAR: (departure from Madagascar) MOYEN DE TRANSPORT UTILISɠ: (Means of transportation)INDICATION DE VOS ADRESSES A MADAGASCAR PENDANT VOTRE SJOUR ET CONDITIONS DE VOTRE HBERGEMENT: (Give your addresses in Madagascar during your stay and housing conditions) IMPORTANT: JE MENGAGE A NACCEPTER AUCUN EMPLOI REMUNR OU AU PAIR DURANT MON SJOUR A MADAGASCAR, NE PAS CHERCHER MY INSTALLER DFINITIVEMENT ET QUITTER LE TERRITOIRE MALGACHE LEXPIRATION DU VISA QUI ME SERA VENTUELLEMENT ACCORD. (I agree to comply with the Laws not to engage in any salary nor to engage in any au pair position during my stay in Madagascar, and not to settle down definitely and leave the Territory upon the expiration of my visa). MA SIGNATURE ENGAGE MA RESPONSABILIT ET MEXPOSE, EN SUS DE POURSUITES PRVUES PAR LA LOI EN CAS DE FAUSSE DCLARATION, ME VOIR REFUSER TOUT VISA LAVENIR. (My signature renders me responsible for the above statement and in case of any falsification therein, in addition to any penalties imposed by Law, I understand that I would be unable, in the future, to receive any Malagasy visa) Fait ..............................................................., le ............/.............../ 20 ......... SIGNATUREN EXACT DU BILLET ALLER-RETOUR ( ) OU ATTESTATION DE LAGENCE AYANT DLIVR CE BILLET ( ). (Exact nr. of to and back flight ticket ( ) or Certification by the agency issuing that ticket ( ))La demande de visa nest recevable que si le formulaire est complt ENTIREMENT et SIGN. Pour toutes informations complmentaires, adressez-vous lAmbassade. Aucun document accompagnant la demande de visa ne sera retourn lexpditeur, lexception de: Passeport, certificat mdical et tickets. Si le passeport doit tre renvoy par la poste, veuillez nous faire parvenir une enveloppe pr-affranchie pour un envoi recommand. 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