EMBASSY OF THE FEDERAL REPUBLIC OF NIGERIA

(EMBAIXADA DA REPBLICA FEDERAL DA NIGRIA)

BRASILIA, BRAZIL

PHOTO (FOTO)

APPLICATION FORM FOR VISA/ENTRY PERMIT

3 x 4

(FORMULRIO DE PEDIDO DE VISTO/PERMISSO DE ENTRADA NA NIGRIA)

Form (Formulrio) Imm. 22

This form must be completed in full, and in capital letters.

(Este formulrio deve ser preenchido em letra de forma)

NOTE : VISA FEES ARE NON REFUNDABLE.

(OBS: AS TAXAS DOS VISTOS NO SO REEMBOLSVEIS)

1. Surname: ___________________________________________ Other Names: _____________________________

(Sobrenome)

(Outros nomes)

________________________________________________________________________________________________
2. (a) Sex (Sexo): M
F
(b) Marital Status (Estado Civil): _______________ (c) CPF No: ___________________
3. (a) Present Nationality: ______________________________(b) Previous Nationality: ________________________________
(Nacionalidade Atual)

(Nacionalidade Anterior)

4. (a) Date of Birth (day/month/year): ______________________ (b) Place of Birth: __________________________

{Data de Nascimento (dia/ms/ano)}

(Local de Nascimento)

5. (a) Mothers Name: ____________________________________________________________________________

(Nome da Me)

(b) Fathers Name: _____________________________________________________________________________

(Nome do Pai)

6. Residential Address: ____________________________________________________________________________

(Endereo Residencial)

CEP: _____________________________ Tel (Fone): ______________________ Fax: ______________________

7. Office Address: _______________________________________________________________________________
(Endereo Profissional)

CEP: _____________________________ Tel (Fone): ______________________ Fax: ______________________

8. Profession: _________________________________ Email: ____________________________________________

(Profisso)

9. Colour of hair: __________________ Colour of eyes: ______________________ Height: ____________________

(Cor do cabelo)

(Cor dos olhos)

(Altura)

10. Visible identification marks (Traos visveis de identificao): ______________________________________________

11. Passport No: ______________________ Date of issue: _________________ Date of expiry: _____________________
o

(N do Passaporte)

(Data de emisso)

(Vlido at)

Place of issue: ______________________ Issuing Government/Authority: ________________________________

(Local de emisso)

(Governo/rgo Expedidor)

Yes

12. Are you serving/had served in your countrys Armed Forces?

(Est prestando/j prestou servio militar em seu pas?)

No

(Sim)

(No)

If Yes, what branch of the Service? _____________________________ Period of Service: ___________________

(Caso afirmativo, em qual Arma?)

(Tempo de Servio)

13. (a) Type of Visa required: Diplomatic
Official
Transit
Tourist
Business
TWP
STR

(Tipo de Visto solicitado) (Diplomtico)

(b) No of Entries:
o

(N . de Entradas)

(Oficial)

(Trnsito)

(Turista)

(Negcios)

Single
Multiple
(c) Intended duration of stay: ___________________________

(Uma)

( Mltiplas)

(Tempo de permanncia pretendido na Nigria)

(d) Purpose of journey (please give full details) {Qual o motivo da viagem (favor informar em detalhes)} ______________
____________________________________________________________________________________________

14. (a) Proposed date of travel: ________________________ (b). Mode of travel: _____________________________
(Data prevista para realizar a viagem)

( Meio de transporte)

15. How much money is available for your trip: ________________________________________________________

(Quanto (em dinheiro) tem disponibilizado para a viagem)

(US Dollars/Brazilian Reais => Dlares Americanos/Reais )

16. If your reason for journey to Nigeria is for employment, state (Se o motivo da viagem para a Nigria for emprego, indicar):
Name of Employers (Nomes dos Empregadores): _______________________________________________________
(a) Post to be occupied (Cargo a ser preenchido): ______________________________________________________
(b) Give a full description of job (Descreve em detalhes o tipo de emprego): __________________________________
17. If joining Spouses/Parents or relatives, please give full particulars of the person(s) in Nigeria including the
residential address (Se o solicitante pretender se reunir com seu (s) Cnjuge/Parentes ou familiares, favor enumerar os dados
pessoais da (s) pessoa (s) na Nigria incluindo o seu endereo residencial):

_______________________________________

____________________________________________________________________________________________
18. How long has/have your spouse/parents lived in Nigeria: ______________________________________________
(H quanto tempo mora (m) seu (s) cnjuge/parentes na Nigria)

19. Intended address in Nigeria (Not P. O. BOX) {Endereo na Nigria (Caixa postal no ser aceita)}: ___________________
____________________________________________________________________________________________
20. Have you ever applied for a Nigerian visa before? Yes
No
; If Yes, where: __________________
(J solicitou antes visto de entrada na Nigria?)

(Sim)

( No)

(Se afirmativo, onde)

(City/Country)
(Cidade/Pas)

21. Was visa granted? _____________________ If No, give reason ________________________________________

(O Visto foi concedido?)

(Se Negativo, Explicar o porqu)

Yes (Sim)
No ( No)

22. Have you ever visited Nigeria before? (J esteve Nigria?)

23. If yes, state type of visa issued:

Diplomatic
Official
Transit
Tourist
Business
TWP
STR

(Se afirmativo, indicar o tipo do visto concedido) : (Diplomtico)

(Oficial)

(Trnsito)

(Turismo)

(Negcios)

24. State the period of these visits and the addresses at which you stayed in Nigeria:
(Enumere os perodos em que visitou e os endereos de permanncia na Nigria)

From (De)

To (At)

Address (Endereo)

i.) ___________________

____________________

___________________________________________

ii.) ___________________

____________________

___________________________________________

iii.) ___________________

____________________

___________________________________________

25. How long have you lived in the country where you are applying for visa? _________________________________
(Desde quando mora no pas de onde est solicitando visto?)

26. ALL APPLICANTS MUST COMPLETE THE FOLLOWING: Have you ever:
(TODOS OS SOLICITANTES DEVEM PREENCHER OS SEGUINTES TENS: Voc j:)

(a) been infected by any contagious disease (e.g. Tuberculosis) or suffered serious mental illness?
(contraiu doenas infecto-contagiosas (ex. Tuberculose) ou sofrido de distrbio mental grave?)

(b) been arrested/convicted or pardoned for any crime in the course of any legal action?
(foi preso(a) /condenado (a) ou absolvido (a) por quaisquer crimes em processos judiciais?)

(c) been involved in narcotic activities?

(teve envolvimento com atividades relacionados com narcticos?)

(d) been deported?

(foi deportado?)

(e) sought to obtain a visa by misrepresentation or fraud?

(solicitou visto por meio fraudulento ou falsa declarao?)

(f) tested positive for HIV/AIDS?

(teve resultado positivo em exame de HIV/AIDS?)

Yes

No

(Sim)

(No)

27. Name countries and cities you have lived in for more than a year during the last five years:
(Nomes dos pases e cidades em que morou por um perodo de mais de um ano nos ltimos cinco anos)

Country (Pas)

City (Cidade)

Date (Data)

__________________________
__________________________
__________________________
__________________________

_____________________
_____________________
_____________________
_____________________

____________________________
____________________________
____________________________
____________________________

28. Name the countries which you have visited during the last twelve (12) months?
(Nomes dos pases que visitou nos ltimos (12) meses?)

Country (Pas)

City (Cidade)

Date (Data)

__________________________
__________________________
__________________________
__________________________

_____________________
_____________________
_____________________
_____________________

____________________________
____________________________
____________________________
____________________________

29. Declaration: I declare that the above personal data are true. Any misleading information will lead to the rejection
and denial of entry visa. I fully understand and accept the requirements for the issuance of visa to Nigeria.
(Declarao: Declaro que os dados pessoais acima so verdadeiros. Quaisquer informaes falsas/enganosas resultaro na rejeio
desta solicitao e na recusa do visto solicitado. Compreendo plenamente e aceito os requisitos para a emisso de visto de entrada na
Nigria.)

Signature (Assinatura): __________________________________ Date (Data): _______________________________

For official use only (Para uso oficial):

DATE

REMARKS