2113267452

)MP1.fcTE WITH CAPITAL

$AMHMJIR

y:nt:nai6y>njjC5

KINGDOM OF CAMBODIA

mruipigifni APPLICATION FORM VISA ON ARRIVAL

BTTER

si«innw

Surnamc:

muna Glv?n oamr:	WMH		............-.....U	M;.l< 3J K-mal
SfrtgtiAudta Place of birth:	RUSSIA		...................0
Datc of birth:	nn/MM/rrrr po>KgeHua	wnjin Nationnlits:	RUSSIA
coensttfesuaB Passpórt N*: .	HOMEP IlACnOPTA	Profession: .

Tłłotograph

•*«•*** pł*A*rt|Jfc

4X6

• RATA BhlflAHM IlACnOPTA • ' •    CPOK MCTE4EHMH IlACriOPTA

Dalr pawport tisued:    Datę passpórt cspircs:

fflitnyfBfi Port of estry: łnwratftaHBtrara

Permancnt addrm:

PHNOM PENH

nnn

From:.

BANGKOK

lW8HtcpwtDtCÓo7lI

Flight/Ship/Car N* :

HOMEP PEtóCA

......................K-rnail:    ...........................................................

jnftKDtfwiHlnytJi Addrw in Cambodia:

3flECb AflPEC B KAMBOtOKE. OTEJlb HJ1M flP.

Drtaib <>f CbBdlta iindcr I 2 \e:»rs Old tncfaded in jfOOT passpórt vsho arc trasclling with sou KKtOPMAOKfl 0 nEfflX DO 12 JIET. KOT.OPME JETflT—C_.JBAMM_

wmh

KATA POJKflEHHH

Datc of birth :.......UL*. J MM..:.. J~

Datc of birth:.......\.\U, J MM....../..

Purpose of *i*it: UEJIb BM3MTA

BUSINESS    I engthofstav ^{3 M0OTHS}

HA KAKOtt riEPMOn

Visa typc (Choosc one only)

9tfmm0ftJBłfiivTourisl v»a (T) □    9tpmiGHrTVOrdinary vim    (E)^( etIlmitiJnWOflficial vi*a (B)D

gtfłfmmWftLSpecud vi$a (K) □    Sgimmiiyn^D.plomatic vi»a (A)D tttfimntsnmiYCourtcsy visa(C)□

ttiJłWOlher ....................................................................“^mk ............................................

I (kclart tfaat tbc Information giv» on thh (orm U correct to the best of my kmmledge and belief.

For offtcial usc only

RATA BbE3flA

Datc.. .i    .J. i.Y.D..

Signature

nOWTWCb