| 1. | Surname: | ______________________________________________ |
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| Other Names: | ______________________________________________ |
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| Former Name(s): | ______________________________________________ |
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| 2. | Date and place of birth: | ______________________________________________ |
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| 3. | Nationality: | ______________________________________________ |
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| 4. | Sex: | ______________________________________________ |
| 5. | Passport No: | ______________________________________________ |
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| Date passport issued: | ______________________________________________ |
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| Date passport expires: | ______________________________________________ |
| 6. | Home address: | ______________________________________________ |
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| Telephone No: | ______________________________________________ |
| 7. | Present employer: | ______________________________________________ |
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| Business telephone no: | ______________________________________________ |
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| 8. | Occupation - Present: | ______________________________________________ |
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| Occupation - Former | ______________________________________________ |
| 9. | Marital Status: | Married / Single / Divorced _________________________ |
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| 10. | Names, places and dates of birth of any children accompanying applicant: | ______________________________________________ ______________________________________________ ______________________________________________ |
| 11. | Visa Required - Type | Entry transit / single journey (in transit / for short visit) / multiple _____________________________________________ | |
| Class: | Diplomatic / Official / Ordinary ______________________ |
| 12. | Proposed date of arrival: | ______________________________________________ |
|
| Duration of stay: | ______________________________________________ |
| 13. | Reason for journey: | ______________________________________________ |
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| 14. | Dates of any previous visits: | ______________________________________________ |
| 15. | If in transit, final destination: | ______________________________________________ |
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| Has a visa been obtained for country of destination: | Yes / Not yet / Not necessary _______________________ |
| 16. Any reference in Uganda: | |||
| Name: | ___________________ |
Name: | ___________________ |
| Address: | ___________________ |
Address: | ___________________ |
| Tel No: | ___________________ |
Tel No : | ___________________ |
| 17. | At what address will you stay in Uganda: | ______________________________________________ ______________________________________________ ______________________________________________ |
| 18. | Any other information: | ______________________________________________ ______________________________________________ |
| DATE | SIGNATURE | |
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