Visa Approval/Reference Number (if any):

* Required for further contact

EMBASSY OF VIETNAM

1233 20

Street, NW, Suite 400

Washington, D.C. 20036

Tel: (202) 861-0737 & (202) 861-2293

Fax: (202) 861-0917

http://www.vietnamembassy.us

VISA

APPLICATION

(FOR NON-VIETNAMESE

PASSPORT HOLDERS)

______

01 Photo

(2 inches x 2 inches)

Glued photo here

01 additional photo

stapled to this form for a

loose -leaf visa request

1. Name (in block letters):

.................................................................................………………………………………….

Family name First name Middle name

2. Date of birth:.................../............./….… …

Date / Month / Year

3. Male:  Female 

4. Place of birth:..............................................

5. Nationality at birth:......................................

Nationality at present:..................................

6. Passport number:........................................

Date of issue:................ ........... ........... .........

Date of expiry:........... ........... ........... ...........

7. Profession:......................................................

Place of employment:.....................................

.................................... ......................... ....

……….…………………………………………

Telephone (Office):…....…....................... .....

8. Present mailing address: (P.O Box Not

Accepted for USPS express mail)

………….………………………………………

…………………………………………………

* Email :………………………….

* Telephone :.......................................

9. Purpose of visit to Vietnam:

…………………………………………………

10. Name, address of your contact (sponsor, host,

hotel…) in Vietnam (if any)

................................................………………

................................................................……

.........................................................................

..………………………………………….…

11. Proposed date of entry:

.......... …./…............/......... .....

Date / Month / Year

Proposed date of exit:

....… … /…………/……........

Date / Month / Year

I solemnly declare that the statements made in this application are true and correct.

Date:…………………………………………………

Signature of Applicant ...............................................

Check list: Before submitting, make sure you have included:

 Original Passport (for a visa sticker request); or  Passport copy (front photo page, for a loose-leaf visa request)

 Completed and signed Application with One Photo glued or stapled;

 Visa Fee: Money Order (or Cashier’s Check); and

 Prepaid USPS Express Mail or FedEx Slip, (if you want your visa be returned by mail).