Annex 2

MINISTRY OF FOREIGN AFFAIRS OF THE REPUBLIC OF TAJIKISTAN

to the Governmental Decree of
the Republic of Tajikistan#122 from 27.02.2009

VISA APPLICATION FORM
Fill out the application form with capital letters (marked with black type)
1. Passport number

2. Place of issue: country

3. Citizenship

City (town)

4. Date of issue

District
5. Date of Expire
Place for color photo
Size 3x4 cm

6. Surname (Last name)
7. First name
8. Middle (other) name
9. Date of Birth

10. Place of Birth: District

City (town)

11.Nationality

12. Sex13. Marital status:

MaleCountryMarried
Divorced

FemaleSingle

14. Permanent address (country, city (town), street, house or apartment`s number, zip code):

15. Telephone number: OfficeFax:

Mobile:16. Name and address your office, institution or type of activity: Name

E-mail address:
Address:

17. Position (if you are a student write “student” if retired, write “retried”). Describe your work (activity):

18. Date of arrival to Tajikistan

19. Date of departure from Tajikistan.
(for extension of visa, indicate the duration ofstay)

20. Number of entries: (single, double, multiple,exit visa)

21. PURPOSE OF VISIT (the category of visa will be identified according to the purpose of visit; therefore, indicate the exact and complete purpose of your visit).

22. Place of stay in the Republic of Tajikistan (name and full address of the hotel. If it is a diplomatic representation, private house, state agency or other place, indicate
the full address):

23. Telephone number of theplace of your stay: Office:

Fax:

Mobile:24. Who will pay for your trip (is case of need, consular officer may requestprove of availability of funds, necessary to stay in the Republic of Tajikistan)

26. Have you ever been issued a Tajik visa? If «YES»:
When:
Where:

E-mail address:
25. Have you visited Tajikistan previously? Date and duration of your previous stayin the Republic of Tajikistan?

What type (category):

For how long:27. Have you ever been refused a visa? If «YES»:
When:
Where:

What was you purpose of visit:

28. Do you intend to work in Tajikistan? If «YES», indicate name and address ofemployer:

For how long requested:

29. Do you intend to study in Tajikistan? If «YES», indicate name and address ofthe Institution or University:

30. Please indicate the information about your relatives in the Republic of Tajikistan (father, mother, sister/brother, children, adopted children, spouse, fiancéeetc):

31. IMPORTANT: AFTER HAVING READ THE LISTED BELOW QUESTIONS ATTENTIVELY, PLEASE MARK THE “YES” OR “NO”:- have you ever been arrested or convicted for any offence of crime within theterritory of the Republic of Tajikistan? If answer «YES», please describe it inthe separate page- have you ever been a member of terrorist or extremist group or organization,
human trafficking, weapons and ammunition, illegal drug trafficking and theirprecursors, illegal immigration?
- do you have a criminal record for felony in the territory of the Republic of
Tajikistan or in any other foreign country?
- have you ever been subject of pardon or amnesty?
- did you or do you have infections (contagious) of diseases harmful for thehealth surrounding society?
32. Was this application prepared by another person (organization)? If «YES», then:YESNOYESYESNONOYESYESNO
NOYES

NO

The inviting side is informed that according to the legislation of the Republic of Tajikistan, bears responsibility for authenticity of data indicated in the application as well as for the timely preparationof the documents of the invited foreign citizen for the right of: stay in the Republic of Tajikistan, movement within the territory and for exit from the Republic of Tajikistan upon expiring their definedterm of stay.

who:

relation with applicant:full address and telephone number:date and signature (organization putting astamp):

33. I, hereby certify that after having read the questions listed in the application, I acknowledged the full responsibility for my answers. I am well aware that the false or misleading statement may resultin their permanent refusal of a visa. I understood that possession of a visa does not automatically entitle the bearer to enter the Republic of Tajikistan upon arrival at a point of entry.

Applicant`s signature _________________________________________________

Date _______________________________________________________________

Барои истифодаи хизматїАз љониби корманди консулї пур карда мешавадРаводиди тањти раќами
Категорияи (ба таври пурра)Ба мўњлати (аз кай то кай)Аз љониби (ному насаб, имзова мўњри Консул)Санаи судури раводид