Visa Intake Form

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Visa Intake Form

Title

First Name *

Middle Name

Last Name *

Gender *

Marital Status *

Date of Birth *

Day

Month

Year

Place of Birth *

Present Nationality

Previous Nationality

Color of Hair *

Color of Eye *

Identification Marks

Height (in Feets) *

Residential Address (include apt/unit #) *

City *

State *

ZIP Code *

Contact Phone No. *

Email Address *

Profession *

Office Address (include apt/unit #) *

City *

State *

ZIP Code *

Phone No. *

Issuing Country

Passport Number

Date of Issue

Day

Month

Year

Expiration Date

Day

Month

Year

Place of Issue

Purpose of Journey *

Number of entries required *SingleMultiple

Number of entries

How much money do you have for this trip *

Intended duration of stay (in days) *

Proposed date of travel *

Day

Month

Year

Mode of travel to Nigeria

Intended address in Nigeria

Address *

City *

LGA *

State *

Previous Application Info

Have you ever applied for Nigerian Visa? *YesNo

If Yes, where did you apply for the Visa?

Was the Visa Granted or Rejected *GrantedRejected

Have you ever-visited Nigeria? *YesNo

If Yes, for what reason

State the period of previous visit ‎to Nigeria and address where you stayed

From

Day

Month

Year

To

Day

Month

Year

Address

City

State

LGA

Travel History

How long have you lived in the country where you are applying for visa (in Years)? *

Have you ever been infected by any contagious disease (e.g. tuberculosis,) or suffered serious mental illness *YesNo

Have you ever been arrested or convicted for an offense (even though ‎subject to pardon)? *YesNo

Have you ever been involved in narcotic activity? *YesNo

Have you ever been deported? *YesNo

Have you sought to obtain visa by mis-representation or fraud? *YesNo

If you have served in the military, please state

In which country?

From Date

Day

Month

Year

To Date

Day

Month

Year

Country you have lived for more than one year

Country

City

Date of Depature

Day

Month

Year

Countries you have visited in the last twelve months

Country

City

Date of Depature

Day

Month

Year

I hereby declare that the information given in this application form is correct to the best of my knowledge. Kindly input full name as it appears on your ID.

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