Fill and Sign the General Power of Attorney Form

Visa Approval/Reference Number (if any): EMBASSY OF VIETNAM 1233 20th Street, NW, Suite 400 Washington, D.C. 20036 Tel: (202) 861-0737 & (202) 861-2293 Fax: (202) 861-0917 http://www.vietnamembassy.us VISA APPLICATION (FOR NON-VIETNAMESE PASSPORT HOLDERS) ______ 01 Photo (2 inches x 2 inches) Glued photo here 01 additional photo stapled to this form for a loose -leaf visa request 1. Name (in block letters): .................................................................................…………………………………………. Family name First name Middle name 2. Date of birth:.................../............./….… … Date / Month / Year 3. Male: Female 4. Place of birth:.............................................. 5. Nationality at birth:...................................... Nationality at present:.................................. 6. Passport number:........................................ Date of issue:................ ........... ........... ......... Date of expiry:........... ........... ........... ........... 7. Profession:...................................................... Place of employment:..................................... .................................... ......................... .... ……….………………………………………… Telephone (Office):…....…....................... ..... 8. Present mailing address: (P.O Box Not Accepted) ………….……………………………………… ………………………………………………… ………………………………………………… ………………………………………………… 10. Name, address of your contact (sponsor, host, hotel…) in Vietnam (if any) ................................................……………… ................................................................…… ......................................................................... ......................................................................... ......................................................................... ..………………………………………….… 11. Proposed date of entry: .......... …./…............/......... ..... Date / Month / Year Proposed date of exit: ....… … /…………/……........ Date / Month / Year 12. Requesting a visa good for: • Times of entries: - Single (one time) visit - Multiple visits • Length of stay: - One month - 03 months - Less than 6 Months (with an approval only) - Up to one year (with an approval only) Telephone (Home):....................................... 9. Purpose of visit to Vietnam: ………………………………………………… ………………………………………………… ………………………………………………… I solemnly declare that the statements made in this application are true and correct. Date:………………………………………………… Signature of Applicant ............................................... Check list: Before submitting, make sure you have included: Original Passport (for a visa sticker request); or Passport copy (front photo page, for a loose-leaf visa request) Completed and signed Application with One Photo glued or stapled; Visa Fee: Money Order (or Cashier’s Check); and Prepaid USPS Express Mail or FedEx Slip, (if you want your visa be returned by mail).