EMBASSY OF THE REPUBLIC OF ZAMBIA
2419 Massachusetts Avenue, Telephone: (202) 265-9717
NW Washington, DC 20008 Facsimile: (202) 332-0826
E-mail: embzambia@aol.com www.zambiaembassy.org
VISA APPLICATION FORM
1. Surname: 2. First Name: Middle Name:
3. Date of Birth: Place of Birth:
4. Nationality: Sex:
5. Profession: Business Telephone No.
( )
6. Nationality of Parents at time of Birth:
7. Passport No.
Date of Issue:
8. Place of Issue:
Date of Expiration:
1. If accompanied by your spouse or children, give the following particulars: (Note: Every applicant fills out an individual form)
Full Name (s) Date & Place of Birth Relationship
10. Present Address:
Telephone No.
( ) Email:
1. Permanent Address:
Telephone No.
( ) Email:
2. (a) Type of Visa Requested: Tourist ( ) Business ( ) Church Business ( ) Visitor ( ) Diplomatic ( )
Official ( ) Student ( ) Transit ( ) Volunteer ( ) Courtesy ( )
(b) Entry requested: Single ( ) Double ( ) Multiple ( )
(a) Date of entry into Zambia: ________________________________
(b) Length of Stay in Zambia: ________________________________
13. Final Destination of Journey in Zambia: Address in Zambia:
1. Expected Departure Date from Zambia: Next Destination from Zambia:
1. Duration and Particulars of any previous residence or visits in Zambia:
2. If traveling on business, please list names and addresses of persons to be visited in Zambia:
3. If visiting relatives or friends, please list names and addresses of persons to be visited in Zambia:
18. Signature of Applicant:_______________________________________________________ Date:__________________
For official use only:
Date Tag #
Visa fee Rush Fee Payment Visa # Receipt# Notations
Rev. 04/2006
