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VISA APPLICATION (APPLICATION FOR UKRAINE ENTRY CLEARANCE) Please write in BLOCK CAPITALS and tick all the relevant boxes. 1. SURNAME (as written in your passport) 2. FULL NAME (as written in your passport) PHOTOGRAPH 35 x 45 mm 3. OTHER NAMES OR SURNAMES USED IN THE PAST 4. DATE OF BIRTH day month year FOR OFFICE USE ONLY country А town 5. SEX female # male # ! " Б 6. NATIONALITY present former (if any) В 7. PERSONAL NUMBER Г 8. ADDRESS OF PERMANENT RESIDENCE Д $ % & Е 9. PASSPORT DETAILS type Є number Ж day date of issue month year day valid until month year З issuing authority И THIS VISA APPLICATION FORM HAS BEEN DOWNLOADED FROM WWW.UKRAINIANEMBASSY.ORG.UK PAGE 1 10. MARITAL STATUS single yes married no # yes # # divorced no # yes # widowed no # yes # no # 11. DID YOU SUFFER FROM ANY INFECTIOUS DISEASE DANGEROUS FOR PUBLIC HEALTH? yes # # no 12. HAVE YOU EVER BEEN CHARGED OF ANY CRIMINAL OFFENCES ANYWHERE? yes # # no 13. HAVE YOU EVER BEEN LIMITED OR PROHIBITED FROM AN ENTRY TO UKRAINE? yes # # no IF “YES”, PLEASE SPECIFY WHERE 14. HAVE YOU EVER BEEN DEPORTED OR REMOVED FROM UKRAINE? yes # # no 15. PURPOSE OF YOUR JOURNEY? 16. DURATION OF STAY IN UKRAINE number of days months 17. DATE OF PROPOSED ENTRY TO UKRAINE day month year 18. POINT OF ENTRY TO UKRAINE 19. MEANS OF TRANSPORT FOR ENTRY TO UKRAINE 20. NAME AND ADDRESS OF ORGANIZATION WHICH INVITES NAME AND ADDRESS OF PRIVATE PERSON WHO INVITES THIS VISA APPLICATION FORM HAS BEEN DOWNLOADED FROM WWW.UKRAINIANEMBASSY.ORG.UK PAGE 2 21. CITIES IN UKRAINE YOU INTEND TO VISIT 22. ADDRESS OF TEMPORARY RESIDENCE IN UKRAINE 23. IN CASE OF NEED WHO WILL GIVE YOU FINANCIAL SUPPORT 24. CHILDREN UNDER 16 YEARS OLD INCLUDED ON YOUR PASSPORT AND WHO WILL TRAVEL WITH YOU TO UKRAINE surname name place of birth day date of birth month year nationality 25. IF YOU HAVE BEEN TO UKRAINE, INDICATE THE DATE OF LAST VISIT day month year 26. VISA REQUESTED FOR: single entry # double entry # multiple entry THIS VISA APPLICATION FORM HAS BEEN DOWNLOADED FROM WWW.UKRAINIANEMBASSY.ORG.UK # PAGE 3 THIS PART IS TO BE COMPLETED IN CASE OF TRANSIT THROUGH THE TERRITORY OF UKRAINE 27. COUNTRY OF DESTINATION 28. MEANS OF TRANSPORT TO THE POINT OF DEPARTURE FROM UKRAINE 29. DO YOU HAVE AN ENTRY CLEARANCE FOR THE DESTINATION? yes # # no 30. PLACE OF PROPOSED DEPARTURE FROM UKRAINE TO THE DESTINATION 31. DATE OF PROPOSED DEPARTURE FROM UKRAINE day month year 32. ADDITIONAL INFORMATION I do hereby confirm that I have read and understood everything stated above. I declare that the information given by me in this application to the best of my knowledge is true. I am aware that untruthful data presented by me in this application may serve as a reason to refuse the issue of Ukraine's entry visa and to refuse me to enter Ukraine even in the case the entry visa has been issued. I also know that in the case I am refused to enter Ukraine I am not entitled for any refund of expenses incurred by me. PLACE OF SUBMISSION DATE OF SUBMISSION day month year APPLICANT'S SIGNATURE THIS VISA APPLICATION FORM HAS BEEN DOWNLOADED FROM WWW.UKRAINIANEMBASSY.ORG.UK PAGE 4