Legal Visa Declaration Form

LEGAL VISA DECLARATION FORM

Applicant Name:   Passport Number:   Nationality:

Date of Birth (MM/DD/YYYY):   Place of Birth:

Authorized Representative Name (if any):   Organization:

RECITALS

WHEREAS, the Applicant seeks issuance of a visa or entry authorization to enter the receiving jurisdiction for the purpose and period set forth below; and

WHEREAS, the Applicant understands that certain representations and disclosures are required by law and immigration regulations and that false statements may give rise to civil or criminal liability; and

WHEREAS, the Authorized Representative, if designated by the Applicant, is authorized to receive notices and to act on behalf of the Applicant with respect to verification of submitted documentation and communications with processing authorities.

NOW, THEREFORE, in consideration of the processing of the visa application and the mutual covenants contained herein, the parties declare and agree as follows.

1. DECLARATION OF PURPOSE AND APPLICATION DETAILS

1.1 Visa Category Applied For: . Intended primary purpose of travel: .

1.2 Intended Port of Entry: . Intended date of first entry (MM/DD/YYYY): . Anticipated length of stay: .

2. REPRESENTATIONS, WARRANTIES AND CERTIFICATIONS

2.1 The Applicant represents and warrants that all information provided in connection with this visa application and this declaration is true, complete and correct to the best of the Applicant's knowledge and belief, and that all supporting documents submitted are genuine and unaltered.

2.2 The Applicant certifies that the Applicant will comply with the terms and conditions of any visa or entry authorization granted and will depart the receiving jurisdiction prior to the expiration of any authorized stay, unless lawfully extended.

3. IMMIGRATION, CRIMINAL AND ADJUDICATIVE HISTORY

3.1 Have you ever been refused a visa, denied entry, deported or removed from any country?   Yes   No

3.2 Have you ever been convicted of a criminal offense or are criminal proceedings pending against you?   Yes   No

4. CONSENT TO VERIFICATION AND DISCLOSURE

4.1 The Applicant hereby authorizes any person, institution, law enforcement body, immigration authority, educational institution, employer or financial institution to release to the processing authority or its authorized agents, upon request, records and information necessary to verify any statement made in this application or supporting documents.

4.2 The Applicant consents to background checks, verification of identity and confirmation of immigration and criminal history. The Applicant acknowledges that consent is voluntary but that denial of consent may affect processing.

5. SUPPORTING DOCUMENTS

Indicate all documents attached with this declaration:

Passport copy    Photograph    Financial statements    Invitation or sponsorship letter

Police clearance    Medical examination    Other supporting documents

6. SPONSORSHIP AND FINANCIAL UNDERTAKINGS

Sponsor will provide financial support: Yes    No

7. PENALTIES FOR FALSE STATEMENTS

7.1 The Applicant acknowledges that knowingly making a false statement or submitting fraudulent documents in support of a visa application may constitute a criminal offense punishable by fines and imprisonment, and may result in denial of the application, revocation of any visa issued, deportation, and other immigration penalties.

7.2 The Applicant further acknowledges that civil penalties and administrative sanctions may also apply, and that the issuance of a visa is subject to the receiving jurisdiction's laws and regulations.

8. NOTICES

9. MISCELLANEOUS PROVISIONS

Governing Law: This Declaration shall be governed by and construed in accordance with the laws of the receiving jurisdiction, without regard to conflict of law principles.

Entire Agreement: This Declaration, together with any attachments and the visa application materials expressly incorporated herein, constitutes the entire agreement between the Applicant and the Authorized Representative with respect to the subject matter hereof and supersedes all prior agreements and understandings, oral or written.

Severability: If any provision of this Declaration is held to be illegal, invalid or unenforceable in any respect, such illegality, invalidity or unenforceability shall not affect any other provision of this Declaration and this Declaration shall be construed as if such illegal, invalid or unenforceable provision had not been contained herein.

Amendments and Waiver: No amendment or waiver of any provision of this Declaration shall be effective unless in writing and signed by both parties. The waiver by either party of a breach of any provision of this Declaration shall not operate or be construed as a waiver of any subsequent breach.

Counterparts: This Declaration may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

ACKNOWLEDGMENT

The Applicant certifies under penalty of perjury that the statements made in this Declaration are true and correct to the best of the Applicant's knowledge and that the Applicant understands the consequences of knowingly providing false information.

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