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The Republic of Kazakhstan
VISA APPLICATION FORM
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'1234563!
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Attention!
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Application form should be filled in fully and accurately, in block letters.
Wrong filling of application form can become a cause of refuse in issue of entry visa.
photo
1. $378/Surname(s):_____________________________________________________________________
2. !59/First names: ____________________________________________________________________
3. :;73 <3 5378 =3> ?59/Other names and surnames: _________________________________________
4. @9>919/Sex:
'4/;ale
AB3C/Female
5. $DE?> 2F>8/Date of birth:
2F>8/day
?B9/month
G9C9/year
6. $DE?> G348 (H?C? GI>3 3C)/Place of birth (city and country): _______________________________________________________
7. !;?=?559E9/Nationality: ___________________________________________________________________________________
$DE?> 23;8><378 ?;?=?559E9/Nationality by birth: _________________________________________________________________
8. J5K?19 G?E<?B9/Marital status:
KLB<?H/single
FBC3>73> (2FB3D<3)/married
?G94?1H?>/divorced
5MC 34 (G3184)/widow(er)
9. '734 FBC3>73> (2FB3D<3) KLC1?N9; GMK?B9N9;<9N (;?B9K9N9;<9N) ?59-GO>8> GI>3 ?;?=?559E9> 2O41358N8;/If you
are married, please, inform your spouses full name and nationality: ____________________________________________________
__________________________________________________________________________________________________________
10. $M4?H59 5M4?59> =323>-G?B9/Your permanent home address: __________________________________________________
________________________________________________________53C/tel. ____________________________________________
11. 0?=?><9E9 GI>3 C?D?;9=9/Occupation (educational background and position): ____________________________________
__________________________________________________________________________________________________________
12. @M=91 L4>9/Place of work:________________________________________________________________________________
=323>-G?B9/address:______________________________________________________53C/tel.____________________________
13. (?16L45 5F48/Type of passport:
<P6CL=?559H/diplomatic
H9;=35582/service
MC559H/ordinary
K?1H? HMG?5 5F48/other type of document
%O=848/Number: ___________________________K348C73> 2F>8/date of issue: __________________K348C73> G348/issued by:
___________________________________________________HLC<?>91 =34;8=8/valid till:________________________________
14. $DE?> 3C8>3> 591 5M4?59> ?<?=<?4 FQ8>: 5M4?59> =3=C32358>3 H?B5DE? 4MH1?59 K?4 =??/For person who lives outside
of the country of origin: have you got a permission to return to the country of living?:
@LH/No
*?4/Yes
&MH1?59 KLCE?> G?E<?B<?, HMG?5 >O=848> GI>3 HLC<?>91 =34;8=8> 2O41358N8;/If yes, please indicate the number of this
document and its validity:______________________________________________________________________________________
15. *M49> ?;?H15?><? KLCE?>19; K??/Have you visited the Republic of Kazakhstan before?:
@LH/No
,I/Yes
*LCE?> G?E<?B<?, KM49>E9 1?6?4C?49N9;<9N 2F><348> GI>3 =?H1?59> 2O41358N8;/If yes, indicate the date and purpose
of the visit(s): _______________________________________________________________________________________________
__________________________________________________________________________________________________________
16. #8;<8N ?;?H15?> &316DKCP2?19>? 23CD8N8;73 KM49> 4MH1?5 K348C=373> G?E<?B KLC<9 =??/Have you ever been refused
entry to the Republic of Kazakhstan?:
@LH/No
,I/Yes. *?1 5?459CE?> G?E<?B<?, 13K365348> G?;9N9; (H?Q?>
GI>3 28= 4MH1?559 K3473> GLH)/If yes, please give details below (when and by whom):___________________________________
__________________________________________________________________________________________________________
17. #?6?4<9N =?H1?59/Purpose of travel: _______________________________________________________________________
18. ?K9C<?B59> 5?4?6 (=323>-G?B9, 53C.)/Inviting organization (address, tel.):_______________________________________
__________________________________________________________________________________________________________
>3=313 G?D?659 5MCE? 5D4?C9 =IC8=35 (5LC9H ?59-GO>8, =323>-G?B9, 53C.)/or person, arranging your visit to Kazakhstan (full
name, address, tel.):__________________________________________________________________________________________
__________________________________________________________________________________________________________
19. ?;?H15?> &316DKCP2?19><? KLC?59> 6D>255348/Places of destination in the Republic of Kazakhstan:__________________
__________________________________________________________________________________________________________
20. ?;?H15?> &316DKCP2?19><?E9 23C358> K?15?6H9 6D>258/The first place of entry into the Republic of Kazakhstan:_________
__________________________________________________________________________________________________________
21. ?;?H15?><?E9 D?H95Q? 5M4?59> =323>-G?B9/Temporary address in Kazakhstan:__________________________________
__________________________________________________________________________________________________________
22. #8;<8N 1?6?49N9;<9 GI>3 ?;?H15?><? KLCD =34;8=8><3 5M4D Q9E915?49N9;<9 28= H?4G9C?><94?<9?/Who is
paying for your cost of travelling and for your costs of living during your stay in Kazakhstan?:________________________________
__________________________________________________________________________________________________________
23.
?;?H15?><? KLCD =34;8=8>3 1?H5?><94D9N9; K?4 =??/Have you got an insurance for the period of your stay in
Kazakhstan?:
2L=6?>PR19>9N
@LH/No
?5?D9>
*?4/Yes. #?H5?><94D KLCE?> G?E<?B<?, L>9N HLC<?>91 =34;8=8> GI>3 1?H5?><94D
2O41358N8;/If
yes,
please
indicate
its
validity
and
the
name
of
insurance
company:__________________________________________________________________________________________________
24. ?;?H15?> ?4H9C9 54?>;P563> O523> G?E<?B<?, >378;78 K?4?59> =3=C323558N SP;?19 >3=313 5M4DE? 9H5PR4T?59 K?4
=??/In case of transit through Kazakhstan, have you got an entry visa or residence permit for your destination?:
@LH/No
*?4/Yes. *LCE?> G?E<?B<?, K?4?59> =3=C323558/if
yes, indicate the country of
destination:______________________________________284D GL16?4C?>E?> Q32?4? 6D>258>/border point through which entry is
planned:_________________________________________________________________54?>;P558N K?E959> 2O41358N8;/route of
transit:_____________________________________________________________________________________________________
25. #M4?D 1?C9>?59> SP;?>9N =34;8=8/Period of requested visa: from________________ K?15?6
to _____________ <3B8>
26. #M4?D 1?C9>?59> SP;?>9N =I453C878/Number of entries requested:
1
2
3
2O6 =I453C82/multiple
27. *?C?C?49 (18;K3> K8473 GF473> K?C?C?4 6?16L459N9;E? 3>78;8C73> G?E<?B<? E?>? 5LC5949C?<9)/Children (please
indicate whether they are traveling with you and are entered in your passport):
$378, ?59/
Surname, First names
<
$DE?> G348 =3> 2F>8/
Date and plase of birth
!;?=?559E9/Nationality
2
3
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I undertake that the above mentioned personal data are full and correct. I am aware, that wrong data can cause refuse and canceling of
already issued visa. I am obliged to leave the territory of the Republic of Kazakhstan before visa expiration.
I am told, that in accordance with the article 514 of the Tax Code of the Republic of Kazakhstan ' 209-II of the 12 of June 2001 the sum of
money paid as consular fee is not subject for return; the issued visa does not fully guarantee entry into Kazakhstan and will not serve as basis for
compensation in case the authorized bodies of the Republic of Kazakhstan refuse entry for the owner of visa into territory of Kazakhstan.
-F>8 GI>3 G348/
Place and date: _______________________________________
LC9/Signature: ______________________________________
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For official use only
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