SHIS 01 5 CONJUNTO I9 CASA 24 BRASILIA . DF CEP: 71615-190 TELS.: (61) 3248.0874.3248 0875 364-5319 FAX: (61) 3248-0688 E-mail: embguyana@embguyana.org.br




01.     Surname (as in passport)________________

02.     First and Middle Names (as in passport)

03.      Other Names (Maiden, Professional, Aliases etc)

04.    Date and Place of Birth _____________

05.    Nationality_____________________

06.     (a) Passport No. _______ (b) Date and Place Issued _________________ (c) Date Passport Expires _____

07.     Home Address (in Full)

08.     Telephone No ____________ How long resident

09.     Name and Address of Employer ____________

Telephone No

10.     Present Occupation (if retired, past occupation) __

11.    (a)   Sex ___________        (b) Colour of hair _ (c)  Height __________       (d) Colour of Eyes

(e) Complexion ______        (f) Marks of Identification 12.    Marital Status:  (a) Married  _______       (b)  Single _

(c) Widowed ______       (d)  Divorced (e) Separated ______ 13.     Have you ever applied for a Guyana visa before? _______

If yes:    (a)  Where? __________ (b)  When?

(c)    Type __________  (d) Was visa issued? 14.     Who will furnish financial support? _______________

15.                    With whom will you stay in Guyana and the address?


16.     What is the purpose of your visit?

17.     Have you ever visited Guyana before?

18.     Do you intend to work in Guyana? __

19.     If on business, name and address of firm, etc

20.     Have you ever:

(a) been afflicted with contagious diseases (i.e. Tuberculosis) or who has suffered serious mental illness?

(b) Been arrested, convicted for any offence or crime even though subject of a pardon, amnesty, or other such legal action?   ---------------------

(c) Been involved in narcotic activities?     -------------------------------

(d) Been deported from Guyana within the last five (5) years  ------------------------------------------------------------------------

(e) Sought to obtain a visa by misrepresentation or fraud?     .................................................................................

21.     When are you due to arrive in Guyana?

22.     How long do you intend to stay? ___

I certify mat I have read and understand all the above questions and the answers I have given on this form are true and correct to the best of my knowledge and belief. I understand that possession of a visa does not entitle the bearer to enter Guyana at port of entry if he/she is found inadmissible,

Signature: ___________________

Date of Application:


Note: failure to disclose the true purpose of applying for a visa or the submission of false information will result in refusal of entry or expulsion from Guyana.


Valid until

For * Single/Multiple Entry Date issued


.Signature of Controlling Officer *Delete which is not applicable