לארשי
תנידמ
State of Israel
םינפה
דרשמ
Ministry of Interior
פ
/
1
-
Application for entry visa to Israel
פ
: Instructions for completing
application form:
1 .
ʤʰʥʸʧʠʬʤʮʬʥʶʹʤʰʥʮʺʳʸʶʬʠʰ
. 1. Please attach a recent photograph.
2 .
ʺʸʨʮʬ ʤʰʩʠʹʬʠʸʹʩʬʤʱʩʰʫʡʸʡʥʣʮʭʠ
ʸʥʷʩʡ
2. If application is not for the purpose of visit, specify
ʰ ʭʩʫʮʱʮʥʸʡʱʤʡʺʫʮʳʸʶʬʠ
. reasons and supply documentation.
3 .
ʥʠʺʩʸʡʲʡʭʩʠʡʤʭʩʨʸʴʤʺʠʠʬʮʬʠʰ
3. Please fill in following details in Hebrew or
ʺʩʬʢʰʠʡ
. English.
ʤʧʴʹʮʭʹ
Family name
ʩʨʸʴʭʹ
Given name
ʡʠʤʭʹ
Father’s name
ʭʠʤʭʹ
Mother’s name
ʭʩʮʣʥʷʺʥʮʹ
Previous family name
ʤʣʩʬʭʥʷʮ
Place of birth
ʤʣʩʬʪʩʸʠʺ
Date of birth
ʣʩʧʬʹʮ
Occupation
ʺʩʧʫʥʰʺʥʧʸʦʠ
Present nationality
ʺʮʣʥʷʺʥʧʸʦʠ
Previous nationality
ʩʺʧʴʹʮʡʶʮ
Family status
□
ʯʥʫʸʣ
Passport
□
□
ʸʡʲʮʺʣʥʲʺ
Laissez passer
□
ʺʩʸʡʲʡ
□
ʷʥʥʸ
/
ʤ
□
ʩʥʹʰ
/
ʤʠ
□
ʹʥʸʢ
/
ʤ
□
ʯʮʬʠ
/
ʤʰ
ʸʴʱʮ
number
ʲʯʺʩʰ
"
ʩ
Issued at
ʪʩʸʠʺʡʯʺʩʰ
Issued on
ʣʲʳʷʥʺʡ
valid until
In English
□ married □ single
□ widowed □ divorced
ʬʠʸʹʩʬʤʱʩʰʫʤʺʸʨʮ
Purpose of entry into Israel
ʲ ʤʠʶʥʤʹʸʡʲʮʺʣʥʲʺ ʪʺʥʹʸʡʭʠ
"
ʤʲʥʡʷʤʪʺʡʩʹʩʺʰʩʣʮʩ
,
ʭʠʯʩʩʶ ʠʰʠ
ʤʴʷʥʺʤʮʥʸʦʥʧʺʸʹʠʪʬʤʷʰʲʥʤ
.
If you hold a Laissez-Passer issued by the State of your permanent residence, state whether you have a return visa and indicate its validity.
ʥʧʡʲʥʡʷʤʯʲʮʤ
"
ʬ
permanent address abroad
ʵʸʠʤ
Country
ʸʩʲʤ
City
ʺʩʡʤʸʴʱʮʥʡʥʧʸʤ
Street and house no.
ʯʥʴʬʨʤʸʴʱʮ
telephone no.
ʬʠʸʹʩʡʺʡʥʺʫʤ
Address in Israel
ʤʱʩʰʫʤʭʥʷʮʥʪʩʸʠʺ ʬʠʸʹʩʬʸʲʥʹʮʤ
Anticipated date and place of entry to
Israel
ʺʥʤʹʤʯʮʦ ʸʲʥʹʮʤ
Approximate duration of stay
ʸʡʲʮʺʥʶʸʠ
Countries of
transit
ʥʩʤʹʩʫʩʸʠʺ ʬʠʸʹʩʡʺʥʮʣʥʷʺ
Dates of previous stays in Israel
ʤʡʩʹʩʯʥʩʹʩʸʢʥʱʤʦʩʠʩʴʬ )
ʸʥʷʩʡ
/
ʩʲʸʠ
/
ʡʹʥʺ
/
ʤʬʥʲ
/
ʤʣʥʡʲ
(
Category of residence permit (visitor, temporary resident, resident, immigrant, work)
פ
particulars of dependants included in the application
/ spouse
ʤʧʴʹʮʤʭʹ
family name
ʩʨʸʴʭʹ
given name
ʭʩʸʥʲʰʭʹ
maiden name
ʡʠʤʭʹ
father’s name
ʤʣʩʬʭʥʷʮ
place of birth
ʤʣʩʬʤʪʩʸʠʺ
Date of birth
18 Children under the age of
18
ʩʨʸʴʭʹ
Given name
ʤʣʩʬʤʭʥʷʮ
Place of birth
ʤʣʩʬʤʪʩʸʠʺ
Date of birth
1 .
2 .
3 .
/ Relation/references in
Israel
ʭʹ
Name
ʤʡʸʷʤʱʧʩ
relationship
ʺʡʥʺʫ
address
1 .
2 .
declaration
ʰʥʫʰ ʬʩʲʬʥʸʱʮʰʹʭʩʨʸʴʤʹʸʩʤʶʮʩʰʠ ʩʺʹʷʡʡ ʯʥʩʣʬʣʥʱʩʭʩʥʥʤʮʭʤʹʤʸʫʤʡ ʥʸʱʮʰʥʭʩ
.
ʯʫʥʮʫ
,
ʤʦʡ ʸʩʤʶʮʩʰʠ
ʺʩʬʩʬʴ ʤʸʩʡʲ ʩʺʸʡʲ ʠʬʹ
.
ʬʠʸʹʩ ʺʰʩʣʮ ʯʥʧʨʡʥ ʩʣʥʤʩʤ ʭʲʤ ʣʢʰ ʩʺʬʲʴʠʬ
.
ʺʠ ʯʫʱʬ ʤʬʥʬʲʤ ʤʬʧʮʡ ʩʺʩʬʧʠʬ
ʸʥʡʩʶʤʺʥʠʩʸʡ
.
ʩʤʹʬʫʤʰʩʣʮʬʹʤʸʨʹʮʤʩʣʩʬʲʹʷʥʡʮʩʰʰʩʠʥʩʨʥʴʩʹʸʶʲʮʥʶʩʣʢʰʭʩʩʷʠʬ
.
ʩʰʠ ʸʩʤʶʮ
/
ʵʸʠʬ ʤʱʩʰʫ ʡʥʸʩʱ ʠʬʥʤʷʧʸʤ ʥʶ ʩʣʢʰʫ ʭʩʩʷ ʠʬʹʺʠʦʡ ʤ
,
ʸʥʮʠʫʤʲʩʰʮ ʩʣʢʰʫʹʩʥ ʤʣʩʮʡʹʩʬ ʲʥʣʩ
,
ʰʫʩʤʬʺʥʸʹʴʠʩʰʮʮʲʰʮʺ ʱ
ʩʺʲʢʤʤʰʮʮʤʰʩʣʮʬʸʦʧʥʠʥʬʠʸʹʩʬ
.
ʬʠʸʹʩʡʭʩʰʴʤʣʸʹʮʺʥʫʮʱʬʥʨʩʡ ʭʥʹʮʤʸʹʠʤʺʬʡʷʡʯʩʠʩʫʩʬʲʥʣʩ
,
ʬʠʸʹʩʺʰʩʣʮʩʮʥʧʺʬʩʺʱʩʰʫʡʸʱʬ
,
ʭʠʡ
ʱʩ ʭʩʡʦʥʫʭʩʨʸʴʪʮʱʬʲʤʬʡʷʺʤʤʸʹʠʤʹʸʡʺ
.
I declare that the particulars contained in this application are correct and have been made in awareness of the fact that they are to serve as basis for the consideration of my application. I also declare that I have not committed any criminal offence or any act directed against the Jewish people or the security of the state of Israel and that I am not affected with any illness which might endanger public health. There is no judicial warrant against me and I am not wanted by the police of any country.
I hereby declare that I have not been issued with a restraining order. Furthermore, I have not been denied entry into Israel. I am aware that if a preventive order of this kind has been issued against me, I will be denied entry into Israel, and will be sent back to my country of origin.
I am also aware that the receipt of a visa does not in any way invalidate the right of the Israel Ministry of the Interior to deny my entry into the territory of the State of Israel, if it becomes clear that the visa was issued on the basis of false information.
ʭʥʷʮʤ
place
ʪʩʸʠʺ
date
ʺʮʩʺʧ ʹʷʡʮʤ
Applicant’s signature
ʱʮʤʸʹʠʺʷʰʲʤ
'
ʤʸʹʠʤʢʥʱ
ʪʩʸʠʺ
ʣʲʤʸʹʠʤʳʷʥʺ
ʬʹʺʥʤʹʬʤʴʩ
ʺʧʠʤʱʩʰʫ
/
ʺʥʣʧʠʺʥʱʩʰʫ
