ࡱ> 3 .jbjb^^ -h<h<l66668nT6C" 0: : : : $3L!N!N!N!N!N!N!," %z! | z!: : S 0: : L!L!8WUL&66(PC"C"h%%REPBLICA FEDERATIVA DO BRASIL MINISTRIO DAS RELAES EXTERIORES EMBAIXADA EM OTTAWAProtocol numberVisa number VISA APPLICATION FORM 01 - Full name (as per passport; do not abbreviate or omit any name) First Middle Last  FORMTEXT       FORMTEXT       FORMTEXT      Attach photo here02 - Place of birth (city/state/country)03 - Date of birth Day Month Year size: 40 mm x 35mm (1 9/6 x 1 3/8 inches) FORMTEXT        FORMTEXT    FORMTEXT    FORMTEXT     04 - Country of citizenship  FORMTEXT       05 - Sex male  FORMCHECKBOX  female  FORMCHECKBOX  06 - Marital status  FORMTEXT       white or off-white background 07 - Passport # 08 - Issuing country 09 - Expiration date Day Month Year front view, full face FORMTEXT       FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT     must be recent picture10 - Parent s full name (do not abbreviate or omit any name) and country of citizenshipFather s: FORMTEXT      Mother s: FORMTEXT      11  Highest level of education (check only one box)  FORMCHECKBOX  no diploma  FORMCHECKBOX  high school diploma or the equivalent (e.g., GED)  FORMCHECKBOX  some college credit, but less than one year  FORMCHECKBOX  more than one year of college, but no degree  FORMCHECKBOX  associates degree (e.g., AA, AS)  FORMCHECKBOX  bachelors degree (e.g., BA, AB, BS)  FORMCHECKBOX  masters degree  FORMCHECKBOX  professional degree (e.g., MD, DDS DVM, LLB, JD)  FORMCHECKBOX  doctorate degree12 - Major/primary field of study  FORMTEXT       13 - List any special skill and/or certificates  FORMTEXT       14 - Job position (as per business card) or title  FORMTEXT       15 - Employer (for students, name school/university)  FORMTEXT       16  E-mail:  FORMTEXT       17 - Business address  FORMTEXT       18 - Business telephone # (with area code)  FORMTEXT      19 - Home address  FORMTEXT       20 - Home telephone # (with area code)  FORMTEXT       FOR OFFICIAL USE ONLYA - Consulta SERE OF ( TEL ( No. _______B - Autorizao da SERE DESP ( DESPTEL ( No. ______ C - Tipo do Visto ___________________D - ( Concesso Denegao Impedimento E - ( Uma entrada ( Mltiplas entradas F - Validade _____________anos/diasG - Data ______/______/______H - Observaes I - Assinaturas Funcionrio Chefia Embaixada do Brasil em Ottawa/VisaForm.Doc Updated: May 2001 21 - Purpose of trip (check item that is the most applicable to the circumstances of your trip)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Provide services in Brazil of a temporary nature, including activities such as office and technical support, installation and repair of equipment, including computer and telecommunications systems, construction activities, and direct supervision of personnel in Brazil U.S.-based personnel involved in business development activities, including negotiating contracts, marketing, opportunity assessments, specifying orders for contracts, customer relations related activities, performance assessments, project reviews, and establishing a framework for doing business in Brazil Direct participation in oil and gas exploration and/or production activities Work under an employment contract with a company/organization in Brazil - i.e., hired under a Brazilian labor contract as a local employee (this applies to the foreign employees of multinationals working in their Brazilian subsidiaries) Transfer of residence to Brazil under permanent residency status Attend conference, seminar or workshop (note under Comments below whether attendee, paid/unpaid speaker, trainer, and provide name of event sponsor) Provide religious or missionary services and/or assistance Provide community and/or medical services Attend school or pursue studies Conduct research or pursue scientific-technologic activities under an international cooperation program Pursue professorial studies/research/teaching and/or pursue scientific/technologic activities at an university, research or similar organization (attach letter specifying conditions: employment contract? research scholarship? ) Participation in athletic or performing arts events (note under Comments below whether paid/unpaid participation) Journalism activities and/or film making As a government official Tourism, visit friend(s) and/or relatives (under Comments below provide further insight on intended trip and, as applicable, list relationship to parties being visited) Other:  FORMTEXT   Comments:  FORMTEXT    FORMTEXT    FORMTEXT   22 - Expected port of entry and date of arrival in Brazil  FORMTEXT       23 - Expected duration of immediate trip  FORMTEXT      24 - Name and address of person, institution or company through whom you can be contacted in Brazil  FORMTEXT       25 - Address in Brazil where you will be staying (e.g., hotel, vessel, friend, other)  FORMTEXT        FORMTEXT       26 - Telephone # in Brazil (with city code)  FORMTEXT       27 - Have you ever been to Brazil?  FORMCHECKBOX  Yes  FORMCHECKBOX  No28 - If yes for item 27, provide date, place and duration of last visit  FORMTEXT       IMPORTANT: FORMS THAT ARE INCOMPLETE AND INCORRECTLY FILLED OUT WILL BE RETURNED. CAREFULLY READ AND FOLLOW INSTRUCTIONS AT THE BOTTOM OF THIS PAGE. 29 - I declare that the above information is true and accurate. Name (type or print) Date Signature   FORMTEXT       Day  FORMTEXT      Month  FORMTEXT      Year  FORMTEXT       INSTRUCTIONS Type or write in block letters, on blue or black ink only. Form can be filled out on line. Complete first and second pages, except for box marked  For Offical Use Only. Answer all questions thoroughly and accurately. If a question does not apply, please type N/A. Sign and date each form. Original signature is mandatory (no photocopy).  "DXvwVWab  $&(2468LNPZ\f h    " $ ( * , . B 6jzUjUCJ jU55CJjUjU jUmHj0U6CJCJCJ OJQJmHOJQJ jU>"EYiuvwTsqoi !h$$Ifl\8w")  4 la <d$If$If<$If $If ! 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