CONSULATE OF CHILE IN ASTANA

CONSULAR FORM FOR TOURISTS

1. LAST NAME (As shown in your passport) PAK

2. FIRST AND MIDDLE NAME (As shown in your passport) MARINA

3. OTHER NAMES

4. LAST NAME/NAME OF FATHER PAK ANATOLIY

5. LAST NAME/NAME OF MOTHER PAK SVETLANA

6. SEX: M F

7. DATE OF BIRTH (day/month/year) 02/08/1983

8. PLACE OF BIRTH (City, Province, Country) ALMATY, KAZAKHSTAN

9. LOCAL DOCUMENT TYPE AND Nº: ID 135965845

10. CITIZENSHIP Current Origin KAZAKHSTAN

11. HOME ADDRESS ALMATY, SAMAL 15-230

12. HOME TELEPHONE Nº +7727 3589645

13. PROFESSION ENGINEER

14. MARITAL STATUS MARRIED

15. ACTIVITY ENGINEER

16. EMPLOYER ALTEL LTD

17. BUSINESS TELEPHONE Nº, EMAIL +727 3885566, PAKMARINA@MAIL.RU

18. COLOR OF HAIR BROWN

19. COLOR OF EYES GREY

20. COMPLEXION NORMAL

21. HEIGHT 172 SM

22. PARTICULAR FEATURES N/A

23. PASSPORT Nº / TRAVEL DOCUMENT N12586547

24. PLACE AND DATE OF ISSUANCE MINISTRY OF JUSTICE, 02/08/2010

25. EXPIRATION DATE 02/08/2020

26. TYPE OF VISA 1 ENTRY

27. REASON OF TRAVEL TOURISM

28. LENGTH OF STAY 18 DAYS

29. PARTICULARS OF HOST (Name/Last Name - Address and Phone Nº LOUIS CARLOS SALVADORES, ANFESTE CALLE, +562 89875641

30. ARRIVAL DATE 10-07-2014

31. ADDRESS IN CHILE (Lodging place) ANFESTE CALLE, #1245, SANTIAGO DE CHILE

32. DEPARTURE DATE 28-07-2014

33. SPOUSE (Last name, names, citizenship, date of birth) GRISHIN IGOR, 25/06/1981, KAZAKHSTAN

34. CHILDREN (Last name, names, citizenship, date of birth) NO

35. HAVE YOU APPLIED FOR A VISA BEFORE? YES NO

36. WHEN? YEAR: -

37. WHERE? -

38. DID YOU ENTER? YES NO

39. WHEN? YEAR -

40. LENGTH OF STAY -

41. REASON -

42. ARE ANY OF THE FOLLOWING PEOPLE IN CHILE? Spouse Fiancé Brother Sister Father Mother Other NO

43. LIST THE COUNTRIES WHERE YOU HAVE LIVED FOR MORE THAN SIX MONTH DURING THE LAST 5 YEARS, STARTING WITH YOUR CURRENT COUNTRY OF RESIDENCE. KAZAKHSTAN

AFFIDAVIT: I declare that I am aware that during my stay in Chile I may not carry out gainful activities nor intervene in its internal policy or in acts against its Political Constitution or the Laws, Decrees and other provisions applicable in its territory and promise, during my stay in Chile NOT to apply for a change of my tourist status. I further declare that all the particulars contained in this Application are true. --------------08-06-2014------------------------- ------------------------------------------------------------------------- DATE APPLICANT’S SIGNATURE

CONSULAR FEES

DATE OF VISA

CONSUL’S SIGNATURE AND SEAL

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PRO-VISA APPLICATION FORM	\|

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