PLEASE USE BLOCK CAPITALS

REQUESTED BY:
	DATE OF REQUEST:
AM / PM : 	
Copy of Passport Attached:	Yes / No	
NAME OF TRAVELLER:
		
FUNCTION & GRADE:
(e.g. Lead Counsel, Co-Counsel, Legal Assistant, etc)		
PURPOSE OF TRAVEL:
(e.g. travel on assignment)		
DATE OF TRAVEL:
		
TRAVELLING FROM:
(City of departure & Country)		
Via:
(City and Country)		
TRAVELLING TO:
(City of arrival & Country)		
VISA TO BE ISSUED IN:
(City and Country)		
TYPE OF VISA TO BE ISSUED (circle number of months required):	1 month*; 3 months; 6 months multiple entry	
RESIDENTIAL ADDRESS:
(Address where person requiring visa normally resides, not the address they will be using in the Netherlands).		
CONTACT TELEPHONE NO:		
NATIONALITY:		
DATE OF BIRTH:		
PLACE OF BIRTH (Town & Country):		
PASSPORT NO:		
WHERE PASSPORT ISSUED:		
DATE OF ISSUANCE:		
DATE OF EXPIRY:		
SIGNATURE OF APPLICANT:		
DATE:		
*Please apply for a 1 month multiple entry visa if you need a Ministry of Foreign Affairs Identity Card.