Last Name: *________________________________________
First Name: *________________________________________
Gender: * Male Female
Date of Birth * Day ____ Month ________ Year________
Place of Birth * ______________________________________
Birth Nationality * ____________________________________
Present Nationality: *_________________________________
Passport Number: *___________________________________
Place of Issue: *______________________________________
Date of Issue: *______________________________________
Date of Expiration: *__________________________________
Present Occupation: _______________________________
Employer: _______________________________________
Current Home Address: *____________________________
________________________________________________
Mobile Phone: *___________________________________
Home Phone: _____________________________________
Email Address: *___________________________________
Arrival Date in Cambodia*
Day_____ Month______ Year _________
Exit Date in Cambodia*
Day_____ Month______ Year _________
Jan - Feb - Mar - Apr
May - Jun - Jul - Aug
Sep – Oct – Nov - Dec
Jan - Feb - Mar - Apr
May - Jun - Jul - Aug
Sep – Oct – Nov - Dec
Point of Entry: * ___________________________________
Means of Transportation: ___________________________
Address during the visit: * ___________________________
_________________________________________________
Point of Exit: *_____________________________________
Means of Transportation: ____________________________
First trip to Cambodia: Yes No
Travelling on group tour: Yes No
Tour Company: __________________________________
FOR MAILING VISA REQUESTS
Send to:
Royal Embassy of Cambodia (T-Visa)
4530 16
th
Street N.W.
Washington D.C. 20011
Carrier:
- UPS & FedEx envelope (Recommended) or
- USPS – PRIORITY MAIL envelope with a tracking number.
FOR OFFICIAL USE ONLY:
DATE PROCCESSED __________________
VISA NUMBER ______________________
TYPE OF VISA ______________________
ROYAL EMBASSY OF CAMBODIA
TO THE UNITED STATES OF AMERICA
4530 16
th
Street N.W.
Washington D.C. 20011
www.embassyofcambodiadc.org
,
Application Checklist
Actual (Original) passport
Copy of the passport bio-page
Visa application form with a 2x2 passport photo attached
Fee of US 30$ in cashier’s check or money order only
UPS or FedEx prepaid self-addressed return envelope
KINGDOM OF CAMBODIA
Nation – Religion - King
2 x 2
One (1) Passport picture
Taken within
six (6) months
Securely Attached
Paste or Stapled
L/R (side-to-side)
I hereby declare that the information on this form is true and correct.
________________________
*Signature
_______________________________________________
*Applicant’s Full Name & Date
