‫اﻟﺠــــﻤﻬـــﻮرﻳــــــــﺔ اﻟﺠـﺰاﺋـﺮﻳــــــﺔ اﻟﺪﻳـﻤﻘـﺮاﻃﻴــــــﺔ اﻟﺸـــــــــــﻌـﺒﻴــــــﺔ‬

..........................................................................:‫اﻟﻤﺮآﺰ‬ PEOPLE'S DEMOCRATIC REPUBLIC OF ALGERIA

Post : ………………………………………………….
‫ﻧﻮع اﻟﺘﺄﺷﻴﺮة‬
Visa type ‫ﻃــــــــــﻠــــــﺐ ﺗـــــــﺄﺷــــــــﻴـــــــﺮة‬
…………………….. VISA APPLICATION
‫اﻟﻠﻘﺐ‬ ‫اﻻﺳﻢ‬
‫ﺻـــﻮرة‬
Family name …………………………………………………….. First name ………………………………………………….... Photo
‫اﻹﺳﻢ ﻗﺒﻞ اﻟﺰواج‬ ‫إﺳﻢ اﺧﺮ‬
Maiden name ………………………………………….. Other name ………………………………………………….…
‫ﺗﺎرﻳﺦ و ﻣﻜﺎن اﻟﻤﻴﻼد‬ ‫ﻓﻲ‬ ‫اﻟﺒﻠﺪ‬
Date and place of birth …….. /……….. /……..….. at ……………………… Country ………………………………………
‫إﺑﻦ‬ ‫و إﺑﻦ‬
Father’s name …........................................................................ Mother’s name …..........................................................................................
‫اﻟﺤﺎﻟﺔ اﻟﻌﺎﺋﻠﻴﺔ‬ ‫أﻋﺰب‬ ‫ﻣﺘﺰوج‬ ‫ﻣﻄﻠﻖ‬ ‫أرﻣﻞ‬ ‫ذآﺮ اﻟﺠﻨﺲ‬ ‫أﻧﺜﻰ‬
Marital status(*) Single Married Divorced Widow (er) gender(*) M F
‫اﻟﺠﻨﺴﻴﺔ اﻟﺤﺎﻟﻴﺔ‬ ‫اﻟﺠﻨﺴﻴﺔ اﻷﺻﻠﻴﺔ‬
Present nationality ………………………………………… Nationality of birth …………………………………………………….

‫اﻟﻌﻨﻮان اﻟﺸﺨﺼﻲ‬ ……………………………………………………………………………………………………………….

Personal address …………………………………………………………… Tel …………………………………
‫اﻟﺰوج‬
husband-wife ‫ﺧﺎص ﺑﺎﻹدارة‬
‫اﻟﻠﻘﺐ‬ ‫اﻻﺳﻢ‬ For office use only
Family name ……………………………………………………………………………… First name ……………………………………………………………………………………………………………
‫ﺗﺎرﻳﺦ و ﻣﻜﺎن اﻟﻤﻴﻼد‬ ‫اﻟﺒﻠﺪ‬ ‫اﻟﺠﻨﺴﻴﺔ‬
Date and place of birth ……… /…… /…… Country ……………………………………. Nationality …………………………………………
‫رﻗﻢ اﻟﻄﻠﺐ‬
Application Number
To be filled only if the child is on your passport and traveling with you ‫ﻻ ﻳﻤﻠﺊ إﻻ ﻓﻲ ﺣﺎﻟﺔ ﺳﻔﺮ اﻷوﻻد‬
Children ‫اﻷﻃﻔﺎل‬
‫اﻻﺳﻢ و اﻟﻠﻘﺐ‬ ‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬ ‫ﻣﻜﺎن اﻟﻤﻴﻼد‬ ‫اﻟﺠﻨﺴﻴﺔ‬
Family name – First name Date of birth Place of birth Nationality
‫ﺗﺎرﻳﺦ اﻹﻳﺪاع‬
Received on

Type of travel document ‫ﻃﺒﻴﻌﺔ وﺛﻴﻘﺔ اﻟﺴﻔﺮ‬ ‫ﻋﺪد ﻣﺮات اﻟﺪﺧﻮل اﻟﻤﺮﺧﺼﺔ‬
‫ﺟﻮاز ﺳﻔﺮ ﻋﺎدي‬ (‫وﺛﻴﻘﺔ أﺧﺮى )ﺗﻮﺿﻴﺢ‬ Nbr of authorized entries
Ordinary Passport other document (give precision) ………………………………………………………………………….
‫رﻗﻢ‬
Passport number ‫اﻟﺼﺎدر‬ ‫ﻳﻨﺘﻬﻲ ﻓﻲ‬
……………………………………………………. Issued on …….. /……. /……... Expire on …….. /……. /……... ‫ﻣﺪة اﻹﻗﺎﻣﺔ‬
Authority …………………………………………………………………… Duration of stay
(*) ‫ﺗﺄﺷﻴﺮة ﻣﻄﻠﻮﺑﺔ ﻟﻠﺪﺧﻮل‬ ‫ﻣﺮة واﺣﺪة‬ ‫ﻣﺮﺗﻴﻦ‬ ‫ﻋﺪة ﻣﺮات‬ ‫ﺗﺎرﻳﺦ اﻟﺪﺧﻮل‬
Visa solicited for (*) 1 entry 2 entries Multiple entries Date of entry ………. /………… /………
‫اﻟﻀﺮﻳﺒﺔ اﻟﻤﺴﺘﺤﻘﺔ‬
‫اﻟﻤﻬﻨﺔ‬ ‫اﻟﻤﺴﺘﺨﺪم‬ Tax
occupation …………………………………………………………... employer ………………………………………………………………….
‫اﻟﻌﻨﻮان اﻟﻤﻬﻨﻲ‬ …………………………………………………………………………………………………………………
Company address …………………………………………………………………………………………………………………
‫ﺗﺎرﻳﺦ ﺻﺪور اﻟﺘﺄﺷﻴﺮة‬
‫ﻓﻲ ﺣﺎﻟﺔ ﻋﺒﻮر‬ ‫اﻟﻮﺟﻬﺔ اﻟﻨﻬﺎﺋﻴﺔ‬ Issued on
In case of transit What ’s final destination ………………………………………………………………………………………………..
(*) ‫هﻞ ﻟﺪﻳﻜﻢ ﺗﺄﺷﻴﺮة دﺧﻮل ﻟﻬﺬا اﻟﺒﻠﺪ‬ ‫ﻧﻌﻢ‬ ‫ﻻ‬
Do you have a visa for this country (*) yes no
‫اﻟﻌﻨﻮان أﺛﻨﺎء اﻹﻗﺎﻣﺔ‬ ‫اﻟﺘﺎرﻳﺦ اﻟﻤﺤﺪد ﻟﻼﺳﺘﻌﻤﺎل‬
Address during your stay …………………………………………………………………………………………………………………………………... Expiry date
‫ﻏﺮض اﻹﻗﺎﻣﺔ‬
Purpose of stay …………………………………………………………………………………………………………………………………………...
‫رﺋﻴﺲ اﻟﻤﺮآﺰ‬
‫ﻣﺪة اﻹﻗﺎﻣﺔ‬ ‫ ﻳﻮم‬30 ‫ ﻳﻮم‬90 Others ‫اﺧـــﺮ‬
(‫)اﻹﻣﻀﺎء و اﻟﺨﺘﻢ‬
Length of stay 30 days 90 days ……………………………………………………………………………………………..
Head of the post
(Signature and stamp)
‫هﻞ ﺳﺒﻖ ﻟﻜﻢ اﻹﻗﺎﻣﺔ ﺑﺎﻟﺠﺰاﺋﺮ‬ ‫ﻧﻌﻢ‬ ‫ﻻ‬
Have you been already to Algeria yes no

‫آﻢ‬ ‫ﻓﻲ أي ﺗﺎرﻳﺦ‬ ‫ﻣﺪة اﻹﻗﺎﻣﺔ‬

How many times? ……… When ? ………………………………… Length of stay …………………………………………………….

‫و ﺑﻌﺪم اﻹﻗﺎﻣﺔ ﺑﺼﻔﺔ ﻋﻔﺎﺋﻴﺔ‬،‫أﻟﺘﺰم ﺑﻤﻐﺎدرة اﻹﻗﻠﻴﻢ ﺑﻌﺪ اﻧﻘﻀﺎء أﺟﻞ اﻟﺘﺄﺷﻴﺮة اﻟﺘﻲ ﺳﺘﻤﻨﺢ ﻟﻲ و ﺑﻌﺪم ﻗﺒﻮل أي ﻋﻤﻞ ﻣﺄﺟﻮر أو ﻏﻴﺮ ﻣﺄﺟﻮر ﺧﻼل إﻗﺎﻣﺘﻲ‬
I undertake to leave the Algerian territory at the expiration of the visa, and to refuse any employment being paid or not, during my stay, and do not establish there
‫ ﻓﻲ ﺣﺎﻟﺔ ﺧﻄﺊ أو ﻋﺪم ﻣﻠﺊ ﺑﻌﺾ اﻟﺨﺎﻧﺎت ﻟﻦ ﻳﺮد ﻋﻦ ﻃﻠﺒﻜﻢ‬،‫هﺎم ﺗﻤﻠﺊ ﺟﻤﻴﻊ اﻟﺨﺎﻧﺎت ﺑﺤﺮوف واﺿﺤﺔ‬
IMPORTANT :All categories must be completed in CAPITAL LETTERS in case of mistake or
omission, your demand will be rejected.
(*) put the Cross in the category ‫)*(ﺿﻊ ﻋﻼﻣﺔ × ﻓﻲ اﻟﺠﻮاب اﻟﻤﺨﺘﺎر‬
corresponding to your answer.
(‫ و أﻣﻀـﺎء اﻟﻤﻌﻨﻲ)ﺻــﺎﺣﺐ اﻟﻄـﻠﺐ‬،‫اﻟﺘﺎرﻳﺦ‬
DATE and APPLICANT'S SIGNATURE

MAE – AC 42 .