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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