Email: guyanaembassydc@verizon.net
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| 1. Surname (as in passport) | .................................................. |
| 2. First and Middle Names (as in passport) | .................................................. |
| 3. Other Names (Maiden, Professional, Alias, etc) | .................................................. |
| 4. Date and place of Birth | .................................................. |
| 5. Nationality | .................................................. |
| 6.(a) Passport No | .................................................. |
| (b) Date and Place issued | .................................................. |
| (c) Date Passport Expires | .................................................. |
| 7. Home Address (in full) | .................................................. |
| 8.(a) Telephone No | .................................................. |
| (b) How Long Resident | .................................................. |
| 9.(a) Name and address of Employer | .................................................. |
| (b) Telephone No | .................................................. |
| 10. Present Occupation (if retired, past occupation) | .................................................. |
| 11.(a) Sex | .................................................. |
| (b) Colour of hair | .................................................. |
| (c) Height | .................................................. |
| (d) Colour of Eyes | .................................................. |
| (e) Complexion | .................................................. |
| (f) Marks of Identification | .................................................. |
| 12. Marital Status: (Place X )(a) Married | .................................................. |
| (b) Single | .................................................. |
| (c) Widowed | .................................................. |
| (d) Divorced | .................................................. |
| (e) Separated | .................................................. |
| 13. Have you ever applied for a Guyana visa before? If yes: (a) Where? | .................................................. |
| (b) When? | .................................................. |
| (c) Type | .................................................. |
| (d) Was visa issued | .................................................. |
| 14. Who will furnish financial support? | .................................................. |
| 15. (a) With whom will you stay in Guyana? | .................................................. |
| (b) Address of your host in Guyana | .................................................. |
| 16. What is the purpose of your visit? | .................................................. |
| 17. Have you ever visited Guyana before? | .................................................. |
| 18. Do you intend to work in Guyana? | .................................................. |
| 19. If on business, name and address of firm etc. | .................................................. |
| 20. Have you ever:(a) been afflicted with contagious diseases (e.g., Tuberculosis) or has suffered serious mental illness? | .................................................. |
| (b) been arrested, convicted for any offence or crime even though subject of a pardon, amnesty, or any other such legal action? | .................................................. |
| (c) been involved in narcotic activities? | .................................................. |
| (d) been deported from Guyana within the last five (5) years? | .................................................. |
| (e) Caught trying to obtain a visa by misrepresentation or fraud? | .................................................. |
| 21. When are due to arrive in Guyana? | .................................................. |
| 22. How long do you intent to stay? | .................................................. |
