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Stateof Israel Ministrv of Interior

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Application for entry visa to Israel
for applicationform: Instructions completing l. Please attach recentphotograph. a 2.If application not for the purpose is ofvisit, speci$ reasons supplydocumentation. and fill 3. Please in followins detailsin Hebrewor English.
IIInT]i7nlnU Previous familv name DNi'lEut Mother's name
lNi'l EUI Father's name

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V Passport D Laissezpasser Tl, li7]nl l'lNnl ln.l Issued valid until on

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'nng0tn lsn Family status 't9un '"1, n'lllrl n/pt'n ! i'lN/.rul tr lfl.l Issued at number ilr/ln?N D n/urr.l I In English ! married W single b S s b + s 8 L widowed f1 divorced D 7N']ut.? i10.llil n]un nl'-Tll '"D ilN3]iluJ llDn nT]Dn ln]u]l EN 'lT'tn EN .i'19i7'tn i'ln't n-rruN ;'li7ll,'li'l 17 Pumose of entry into Israel

If you hold a Laissez-Passerissued by the State of your permanent residence, state whether you have a return visa and indicates its validiw.

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7"lnf Dlli7i'llDni'l F rNil Country

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'tluD n]s-tll Countriesof fransit n]iruli'r lnT 'ur'tujnn Approximate durationofstay
-l'lNn i'tu'lli'l E'ti7n't 'u,'tuni'l 7N"tuJ.7 Anticipated date and place ofentry to Israel

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7N']ul.l nt]nln Address in Israel

Honqlonq

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(i'trtlD/it?]u/luln/'ut N/t'ti7'l) i'll' ut' l'tru1'l ]l0 i'lTrN' 97 permit (visitor,temporary resident, resident, of Category residence immiprant.work)

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Stateof Israel Ministry of Interior

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Application for entry visa to Israel
particulars of dependants included in the application i-lltlPll ll'77l1il Tlll E''U'15

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Dateof birth

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nnguni'lEUJ familv name

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declaration

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Stateoflsrael Ministry of Interior

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Application for entry visa to Israel
E.]T'D U'1319 lnll li7nil il]uNilut tlnu' DNl,?N-lul'

I declare that the particulars contained in this application are correct and have been made in awareness the fact that they are to serveas basis for the considerationof my application. I also of 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 againstme, 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.

Applicant's signature

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date

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place

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