12. Type of Passport :

12. Type of Passport : ftal Ordinary Passport K Diplomatic Passport D Service Passport or equivalent 0 Travel document for refugier or apatried Other 13. Passport Numb Serial Number : pp . • • • • . . . . . . . . . . . . . • • • • • . . . . . . . . . . . . . • . . . . . . . . . . 14. Issued by : Anissz17 Of Foie/ //Ps 15. Date of issue 16.-/P‘A/5 16. Valid until : e6 3 17. Profession : .Dei2Z 18. Purpose of Travel : 61 Tourism 0 Affairs 0 Family visit 0 Culture/ Sport 0 Official visit 0 Medical Purpose K Studies 0 Other ( Precise): 19. Type of visa 0 Long validity VShort validity 0 Transit 20. Number of entries : 1=1 Single entry 0 Two entries [V Multiple entries 21. Duration of stay : Number of days- 3.0 22. Arrival date : 23. Border of entry or transit route /1//- fa4/aear Rafra ee 24. Mean of transport : rctt9fj 1/3 - 25.Previous visas : Date Number Place of issue Duration I. 2 11- /5 MAR-6,5-10?? YorL 30 clays 2.fit p9. Alif-Rai Xia /146i/ yod_ ;t2d€,77J- 3. 26. In case of transit, have you un entry permit to entry to Final country 4/1,4 0 No 0 Yes Country of destination: Valid until: . . I . . I. . Voluble du : . . /. . /. . . . Au: ../../... . Motif :(En cas de Refus ou d'Annulation) Delivered by EFTA01186519