‫دوﻟﺔ اﻹﻣﺎرات اﻟﻌرﺑﯾﺔ اﻟﻣﺗﺣدة‬

‫وزارة اﻟداﺧﻠﯾﺔ‬
PHOTO ‫اﻹدارة اﻟﻌﺎﻣﺔ ﻟﻺﻗﺎﻣﺔ وﺷؤون اﻷﺟﺎﻧب‬

2" X 2"
Visa Application ‫طﻠب ﺗﺄﺷﯾرة‬
‫اﻟﺑﻌﺛﺔ‬
BANGKOK
Applicant Information ‫ﺑﯾﺎﻧﺎت ﻣﻘدم اﻟطﻠب‬

Full Name Heng Kreng ‫اﻻﺳم ﺑﺎﻟﻛﺎﻣل‬

Mother's Name ‫ اﺳم اﻷم‬Father's Name ‫اﺳم اﻷب‬

Nget Chanthy Heng Savuth
Profession ‫ اﻟﻣﮭﻧﺔ‬Nationality ‫اﻟﺟﻧﺳﯾﺔ‬
Official (MoEYS) Cambodian
Date of Birth ‫ ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬Place of Birth ‫ﻣﺣل اﻟوﻻدة‬
10 April 1983 Takeo
Place of Issue ‫ ﻣﺣل اﻹﺻدار‬Passport Type & No. ‫ﻧوع ورﻗم اﻟﺟواز‬
Phnom Penh Official Passport: BA0002392
Date of Expiry ‫ ﺗﺎرﯾﺦ اﻹﻧﺗﮭﺎء‬Date of Issue ‫ﺗﺎرﯾﺦ اﻹﺻدار‬
18 May 2027 18 May 2022
Address in UAE ‫ اﻟﻌﻧوان داﺧل اﻹﻣﺎرات‬Country of Residence ‫ﻋﻧوان اﻹﻗﺎﻣﺔ‬
InterContinental Dubai Festival City, IHG Hotel Cambodia
Education ‫ اﻟﻣؤھل اﻟﻌﻠﻣﻲ‬Purpose of Entry ‫اﻟﻐرض ﻣن اﻟزﯾﺎرة‬
PhD Degree 56th Meeting of PISA Governing Board (PGB)
Do you have another nationality? Yes / No - Mention it ‫ اذﻛرھﺎ‬- ‫ ﻻ‬/ ‫ﻧﻌم‬ ‫ھل ﺗﺣﻣل ﺟﻧﺳﯾﺔ أﺧرى ؟‬
No
Have you ever visited the UAE? Yes / No ‫ ﻻ‬/ ‫ﻧﻌم‬ ‫ھل ﺳﺑﻖ ﻟك دﺧول اﻹﻣﺎرات ؟‬
No
Sponser Name & Address ‫اﺳم وﻋﻧوان اﻟﻛﻔﯾل‬
Ministry of Education, Youth and Sport: 80 Blvd, Preah Norodom, Phnom Penh, Cambodia

.‫أﺗﻌﮭد ﺑﺄن أﻛون ﻣﺳؤوﻻ ﻋن ﺿﻣﺎن ﺻﺣﺔ اﻟﻣﻌﻠوﻣﺎت اﻟﻣدوﻧﺔ ﻓﻲ ھذا اﻟطﻠب وﻋن إﻟﺗزاﻣﻲ ﺑﺈﺗﺑﺎع اﻷﻧظﻣﺔ واﻟﻘواﻧﯾن اﻟﻣﺗﺑﻌﺔ ﻓﻲ دوﻟﺔ اﻹﻣﺎرات اﻟﻌرﺑﯾﺔ اﻟﻣﺗﺣدة‬
I hereby declare that the information stated herein is valid and correct, and I shall be committed to the laws
and regulations applicable in the UAE.

Date October 16, 2023 ‫اﻟﺗﺎرﯾﺦ‬

applicant signature ‫ﺗوﻗﯾﻊ ﻣﻘدم اﻟطﻠب‬
 Attached Document Visa Application Page -2-

Education
‫اﻟﺤﺎﻟﺔ اﻟﺘﻌﻠﯿﻤﯿﺔ‬ : PhD Degree
Faculty
‫اﻟﻔﺮع اﻟﻌﻠﻤﻲ‬
: Graduate School of Humanities and Social Sciences
Religion
‫اﻟﺪﯾﺎﻧﺔ‬ : Buddhism
Faith
‫اﻟﻤﺬھﺐ‬
: Buddhism
Marital
Status single X married divorced widowed
Permanent Address
‫اﻟﻌــﻨـﻮان‬
Home address Building\Village Street Sub - District
#12
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District Province Zip Code
Meanchey Phnom Penh 120602
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Mobile No. Tel No.

‫رﻗﻢ اﻟﺠﻮال‬
+85577777934 ‫رﻗﻢ اﻟﮭﺎﺗﻒ‬

E-mail krengheng@gmail.com

Depart from : Phnom Penh Arrival Port : Dubai

Trip info

Trip\Vehicle No. : SQ153 - SQ494 Arrival Date : 22 October 2023

Address in UAE
‫اﻟﻌﻨﻮان داﺧﻞ اﻹﻣﺎرات‬
Hotel / Sponser Name
InterContinental Dubai Festival City, IHG Hotel
‫ اﻟﻜﻔﯿﻞ‬/‫اﺳﻢ اﻟﻔﻨﺪق‬ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

P.O.Box Building
‫ﺻﻨﺪوق اﻟﺒﺮﯾﺪ‬ 45777 ‫اﻟﻤﺒﻨﻰ‬
Dubai

City
‫اﻹﻣﺎرة‬ Dubai Festival City
Area
‫اﻟﻤﻨﻄﻘﺔ‬
Dubai 45777

Street
‫اﻟﺸﺎرع‬

Official Tel No.

‫رﻗﻢ ھﺎﺗﻒ اﻟﻤﻜﺘﺐ‬
+971 4 701 1110

Mobile Tel No.

‫رﻗﻢ اﻟﺠﻮال‬