申請用紙

(1)

キ

ン共和国外務省

Ministry of Foreign Affairs of the Republic of Tajikistan

ビ

/

Visa Application Form

以

必要事項を

ッ

体

記入

い

Application form should be typed or written in block letters

1. パポ番 / Passport

№ 2.

発行場所: 国/Place of issuance: Country 都市/City 地域/Prefecture

カラ証明写真3×4

Color Photo 3×4

TK012345

Japan

Shinjuku-ku

_Tokyo

3. 国籍/Nationality 4.発行日/ Date of issue 5.失効日/ Date of expire

Japanese

01 Jan 2010

01 Jan 2020

6.名字/ Surname

Asia

7. 名前 /Name

Taro

8.セカンネ /Patronimic-Second name

9.生年日/ Date of birth 10.出生地:県/Place of birth: Prefecture 都市/City 国/Country

01 Jan 1980

Tokyo Shinjku-ku

Japan

11. 出身国/Nationality 12. 性別/ Sex 13.婚姻関係/Marital Status

既婚

/ Married

未婚

/ Single

Japanese

男

/Male

女

/Female

_離婚

/ Divorced

14. 現住所 (国,市町村, 区, 番地, 郵便番 )/ Permanent address (country, prefecture, city, street, apartment №, postal zone )

1-1-1 Shimoochiai, Shinjuku-ku, Tokyo, Japan

15. 電番 : 勤務先/ Business

Telephone Number

ッ / Fax 携電 /Mobile / Email address

03-5332-9123 03-5332-9070 090-1234-5678 [email protected]

16. 勤務先学校所属団体:名称/ Name and address of present Employer or School 住所/ Address

Asia Trading Co., Ltd.

1-5-10 Shimoochiai, Shinjuku-ku, Tokyo,

Japan

17. 役職職務 (学校通わい方 «学生», 退職た場合 «退職» 記入い ). 事内容/ Present occupation (if student, write «student», if

retired write «retired» )

Sales

18. 渡航日/ Date of arriving to Tajikistan 19. 国日. 何日間滞在予定 ?/Date of departure

from Tajikistan. If you intend to extend, how long?

20. 出入国回数 ( ンビ , 複数回用ビ )/ Number of entry and exist (single,

double, multiple)

01 Feb 2014

10 Feb 2014

Single Entry

21. 渡航目的 (渡航目的支給ビ種類異明確記入い ) /Trip purpose (type of visa depend on the trip purpose,

therefore give trip purpose in detail)

For business meeting for Japanese finance project

22. キン国内滞在予定先住所 (ホテ名称住所を記入い) 外交官滞在先私邸組織施設そ場所正式名称

郵便番住所を明記い/ Your intended address in Tajikistan (name and address of hotel, if it is diplomatic mission, private house, state institution

or other places give exact name of institution, house number, address, postal zone)

Hyatt Regency: Dushanbe 26/1, Ismoili Somoni Prospekt Dushanbe, Tajikistan 734026

23. 滞在先電番 : 勤務先/

Telephone number of living place: office

ッ /Fax 携電 / Mobile / Email address

+992 48 7002 1234

+992 78 702 1235

_{[email protected]}

24. 渡航費用負担者 (必要応渡航用所持金関書類を提出

う場合あ )/ Who will pay for your trip? (if it is necessary

consul can ask to submit certificate or evidence of cash assets for staying in Tajikistan)

25. 過去キンへ渡航歴あ？渡航た時期滞在期

間を書いい /Have you ever been in the Republic of Tajikistan? When?

For how long? Give previous visits:

Added Value Corporation

7 Oct– 12 Oct 2013

26. 以前キンへ渡航ビを得たあ？得たあ場合以質問答えい/ Have you ever been issued a

Tajikistan visa? If «Yes»

(2)

30 Sep 2013

Embassy in Tokyo

K

18 Oct 2013

27. ビ得を断たあ ? 断たあ場合/ Have you ever been refused a Tajikistan visa if «Yes»

い / When

None

/ Where 渡航目的/ Purpose 前回希望効期間/ For

how long have you asked?

28. キン国内事又商売を予定あ？あ

場合そ会社名称代表者名住所を書いい/ Do you intend

to work in Tajikistan? If «Yes» give the name and complete address of Tajikistan employer

29. キン国内学校等入学予定あ？あ場

合そ学校又施設名称住所を書いい/ do you intend to study in

Tajikistan? If «Yes» give the name and complete address of the school

No

30. キン国内い親族情報を書いい父母姉妹兄弟子息養子婚約者配偶者そ / Give information about your

relatives in Tajikistan (father, mother, sister, brother, children, adoptee, fiancée, spouse and others):

N/A

31.重要：以質問をく読当を付けい/ Important read carefully and mark the appropriate box for each item «Yes» or «No»

-

キ

ン共和国内

い

公安当局

逮捕又

起訴

た

あ

？

あ

場合

別

用紙

細を書い

添付

い

/ have you ever

been arrested or convicted for criminal, civil liability or responsibility under administrative

law in Tajikistan? If «Yes» describe on separate page

い

/Yes

いいえ

/No

-

テ

組織や武闘組織

所属

た

あ

？又

人身売買

武

器や違法薬物

輸出規制違反物

密輸

密入国を行

た

あ

？

Have you ever been member of terrorist or extremist organization, human, arms or

ammunition and illegal drug traffic, organization of illegal migration?

い

/Yes

いいえ

/No

-

キ

ン国内又

外国

重犯罪を犯

服役

た

あ

？

/Have

you convictions for grave crime in the Republic of Tajikistan or other foreign countries

い

/Yes

いいえ

/No

-

以前

法当局

恩赦又

免責を

けた

？

/Have you ever

been granted amnesty or released from punishment

い

/Yes

いいえ

/No

-

ビ

得

キ

ン国内

事や商売を

予定

あ

？

/Will you

engage in business or labor activity on the territory of the Republic of Tajikistan after

obtaining visa?

い

/Yes

いいえ

/No

-

以前

公衆衛生

険

感染症

罹

た

あ

？

/Have you ever been

afflicted with a communicable diseases, which are dangerous for public health

い

/Yes

いいえ

/No

32.当ビ申請書必要事項ビ得希望者本人く代理者組織

た？/

Was this application prepared by another person (organization ) on Your

behalf? If «yes» then by

い

/Yes

いいえ

/No

招待者側へあた申請書記入た情報真実あいう責任を負うキン国法定い渡航者申請書類準備又ビ

失効期限ビ得者国外へ出あた責任 / The inviting side is informed that according to the Legislation of the Republic of Tajikistan,

bears responsibility for authenticity of data indicated in the Application as well as for the timely preparation of the documents of the invited foreign

citizens for the right of stay in the Republic of Tajikistan, transit through its territory and for exit from the Republic of Tajikistan upon expiring their

defined term of stay.

申請書作成者名前又名称:

Who

申請者続柄/Relationship

to applicant

住所及び電番 / Complete address and

telephone number

日付名前組織又会社 / Date

& signature (organizations seal)

33.私申請書内容を理解申請書記載た事項真実あを誓い申請書記載た事項不備又虚偽あ場合ビ発行を一定期間

を理解渡航ビ得国境を越え入国手続完了入国たい /I certify that I have read and understood all the questions set

forth in this application and the answers I have furnished on this form are true and correct. I was informed that any false or misleading statement may

result in the permanent refusal of a visa. I understand that possession of a visa does not automatically entitle the bearer to enter the Republic of Tajikistan

upon passing state border.

ビ希望者署名/Applicant’s signature ______________________ 日付/Date __________________________________