Application for Visa
Republic Of Liberia
Photo
The Liberian Embassy
5201 16
th
Street, NW
Washington, DC 20011
Last Name ___________________________First Name ________________________MI ___ Title ________
Home Address ____________________________________________________________E-mail __________________________
City _____________________State _____ Country _____________________________Phone # ____________________________
Business Address _______________________________________________________Phone # ____________________________
Date of Birth ________________________ Country of Birth ________________________
Current Nationality _________________________Former Nationality (if any) ______________________
Name of Country That Issued Your Passport __________________________________ Passport # _________________
Date of Issue ___________________________Place of issue ____________________ Date of Expiration ________________
Profession/Occupation ___________________________________________________________________________
Have You Visited or Lived in Liberia in the past? ______ List Date of Last Visit or Stay ____________________________
Visa Application part II
Complete this section if the Applicant is officially accompanied by an adult:
Last Name __________________________ First Name ________________________MI ___ Title (circle one): Mr./Mrs./Ms/Dr.
Age _____ Relation to Applicant ______________________________
Visa type: (check one) Single: 1-3 months Multiple: 1 year Multiple: 2 years Multiple: 3 years
Proposed Date of Trip _______________________ Traveling by (check one) Air Sea
Purpose of Trip: (check one) Business Tourism Employment* Official Diplomatic other
Duration of Stay ______ day’s week’s month’s
Contact information of two (2) References in Liberia
1. Last Name __________________ First Name ______________________
*Name of Employer ______________________________________________
Address _____________________________________________________________________________________________
Phone _________________________________
2. Last Name __________________ First Name ______________________
Address _____________________________________________________________________________________________
Phone _________________________________
I hereby certify and declare that each of the above particulars stated by me is true to the best of my knowledge and ability and
that I would be prosecuted for perjuring if found guilty of false information. Any misleading information given will disqualify
me from obtaining a Liberian traveling document.
_________________________________________ Date _______________________
Signature of Applicant
_______________________________________________Date ___________________________
Signature of person filling in form if not same as applicant
For Official Use Only/ to be fille
d by Visa Consular
Visa #__________________ Date of Issuance ____________________ Expiration Date __________________ Approved by: ______________
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