FOREIGN

SERVICE

OF

THE

PHII, IPPINES

Embassy of the Republic

of the

Phil ippines

Seoul,

Korea

APPLICATIONFO R

NON-IMMIGRANT

VISA

(H l4 {a^ l )

F i r s t N a m e M i d d l e

N a m e ( o l € )

u r n a m e ( C )

Dare of birth

{

J

E €-9

t

C iv i l S ta tus :

Sex (dE)

(

)Male(ts)

)Female(€

)

Ase(+ol

:

P lacc

f b i r rh (+^J4) :

7l

€ ) ,

(

)D ivorce(

ol

l l ) ,

(

)o thers :

Spec i f

. z l

4 (

) -

 

) S i n g l e (

l

€ ) ,

(

) M a r r i e d (

I f mar r ied ,

name o f spouse:

( 7 l + . g

+

u l + 4

o l € )

Res idence ddress nd te leohone

umber :

Gl +^e l

dq{ i )

Occupat ion(z l

)

:

C i t i zensh ip(

4

)

Passpor t umber(€

d

C

-q- t

Da te

s s u e d ( € A E l i i E )

Other

persons

rave l l ing under the same

passpor t :

i C a o J

q ? " i l q =

EEgAI " l

g p z l

_a )

Employment addressand telephone

number

(z l ' *

+ae+ d4dE)

Issuedy(4?'93a):

Val id

unr i l r

d

+-n

zl

<I) :

P u r p o s e

f

en t r y t

JE44

t :

In tended ength o f s tay

*S

zl

< l

Date o f depar ture or the Ph i l ipp ines:

(

9l

rl1

.9

a $

s-q

EiLl=zl

g)

Addresswhi le in

he

Phi l ipp ines(94S

. l

+4)

Reference

uarantor

n

the

Phi l ipp ines :

(9-4€q l

q l ! - -

"J4

+41E?)

Ciountry

of dest inat ion af ter t he Phi l ippines

(€qt ]

*€-+

olr .+e+s

El+E;( l

)

Have

you

eve r been re fused a v i sa o f any k i nd , o r

( ge l {

" Jq^ l

zag , ' J

^ }do l

9 t -4n )

(

)Yes

I f

yes .

p l ease

spec i f y :

(rlst

i lrlg

7'146l

€€5i.g,rl

-s -

re fused

ent ry or admiss ion n to the Ph i l ipp ines?

(

) N o

Have

you

v i s i t ed

the

Ph i l i pp ines

be fo re?

(

)Yes

(sJelsg

*E*€

^1. : lo l

=^ l

a)

Dateof last

v is i t (4eql

4 'S^l

7 l

:

)Ncr

I understand that I may

only enter

the Phi l ippines at a Port of Entry, designated

by the

Ph i l i pp ine Immig ra t i on Au tho r i t i e s

and

w i t h

the

pe rm iss ion

o f

and unde r t he cond i t i ons imposed

by those uthor i r ies.(g"Jg

"J+a}" l l

l

"J+d^l+" i

I

so lemn ly swea r t ha t

t he

fo rego ing s ta temen ts a re t r ue t o t he bes t of my know ledge and be l i e f .

(9 le, l

d3r+

s=

^l6Jol^ l€"J+

+E*q4.)

D a t e

( 8 4 )

Signature of Applicant(

(d a

"J.el

^l

H 4

Ee )

(^ - l€

THIS

PORTION

FOR OFFICIAL USE, DO NOT FILL OUT

(ol4

^id,g

7l

"J4^l

pld^l

9. )

Subscribed nd sworn to before

me this

day of

Consul

PHOTO

(^ ld

)

(For

Of f ic ia l Use Only )

V isa No.

Granted

on

__

as

Ph i l i pp ine Immig ra t i on Ac t o f 1940 . as

non- immigrantunder

amended.ec t ion

9(

Va l id

unt i i

Fe e

paid

Remarks . o f anv :

Service

No .

) o f

t he

O.R.No.

Consul