VISA APPLICATION FORM FOR KINGDOM OF BHUTAN

(Please fill in block capital)

1. 	Name in Full: ________________________________________________________ 
(Surname)

2. 	Date of Birth: ____________________________ 
| | | (Day) | (Month) | (Year) | | | | |
3. | Sex : | | Male | | Female | Marital Status: | | Married | | Single |

4. 	Nationality : ____________________________________________ 

5. 	Passport No: _______________________ Place of issue: ____________________ 

Attach passport size Photograph (3.5 x 4.5 cm)

Date of Issue: ___________________  Valid until: ________________________
(DD– MM–YYYY) | | | (DD– MM–YYYY) | |
6.Nature of Passport: | | Diplomatic | | Official | | Ordinary | | UN Laissez Passer |

7. 	Permanent Address: ______________________________________________________________________ 

	__________________________________________________Tel No.___________________________ 

8. 	Occupation/Profession: ________________________________________________________________ 

9. 	Period for which visa is required:  from___________________ to ______________________ 
(DD–MM–YYYY)	(DD–MM–YYYY)

10. 	Port of entry/exit into Bhutan:  Entry Port____________________ Exit Port ______________________ 

11. 	Purpose of visit to Bhutan:________________________________________________________ _____ 

12.Is this your first visit to Bhutan? | | Yes | | No | If No, give details of earlier visit

____________________________________________________________________________________

____________________________________________________________________________________

I hereby declare that the statement given above is true and correct. I fully understand not to indulge in any activity which, are inconsistent with the purpose for which I have stated above. I understand that the period of stay to be granted is decided by the Bhutanese Immigration Authorities upon my arrival.

Date :  __________________

Place:   _________________	Signature of Applicant  ________________

For Official use only

Type of Visa	:____________________________

Visa Number	:____________________________

Date of Issue	: ___________________________

Visa Clearance No.   : ___________________________