פרטי נוסע * • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות ישראלית / Nationality* אזרחות ישראלית / Nationality* תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town / City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality/Region
פרטי תעסוקה וצבא תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל? / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע #2 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #2 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town / City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #2 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality/Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality/Region
פרטי תעסוקה וצבא #2 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #2 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע * #3 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #3 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town / City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #3 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* יש לרשום באנגלית Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality / Region
פרטי תעסוקה וצבא #3 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #3 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע * #4 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #4 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town/ City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #4 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality/Region
פרטי תעסוקה וצבא #4 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #4 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע #5 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #5 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town/City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #5 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality / Region
פרטי תעסוקה וצבא #5 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #5 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע #6 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #6 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town / City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #6 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
מצב משפחתי / Applicant’s marital status* שם בן/בת זוג/ Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality / Region
פרטי תעסוקה וצבא #6 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name/Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל/ Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #6 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*
פרטי נוסע #7 • על הדרכון להיות בתוקף לפחות לעוד 6 חודשים, ולהכיל לפחות 2 דפים ריקים.
• על הפרטים שתזינו להיות זהים לדרכון — אלו הפרטים אשר נשלחים לשגרירות הודו. שם פרטי ושם משפחה באנגלית כפי שמופיע בדרכון / First Name and Last Name in English as in passport*
שם פרטי באנגלית
שם משפחה באנגלית
מספר דרכון / Passport No*
מין / Gender* מקום הנפקת הדרכון / Passport place of issue* • סמנו אם הנפקתם את הדרכון בישראל או מחוצה לה
• הסניף מצוין בסעיף "סמכות ממונה דרכונים" בדרכון
תאריך לידה / Date of birth* ארץ לידה / Country of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
תאריך הנפקת דרכון / Passport Date of issue* תוקף הדרכון / Passport date of Expiry* פרטים אישיים #7 מספר ת.ז / Id Number*
דת / Religion* יהדות / Judaism נצרות / Christian איסלאם / Islam הינדואיזם / Hinduism חסר דת\אחר / No Religion / Other
השכלה / Educational qualification* בבחירת אחר יש למלא את השדה באנגלית.
עיר מגורים / Village / Town / City*
רחוב ומספר בית / House no/Street no*
מיקוד / Zipcode*
מדינה / Country* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אורך שיער / Hair Length* קצוץ / Short קצר / Medium ארוך / Long קרחת / Bald
צבע שיער / Hair Color* שחור / Black חום / Brown בלונדיני / Blonde ג'ינג'י / Readhead אפור / Gray צבע לא טבעי: כחול / ירוק וכדומה / UNnatural קרחת / Bald
צבע עיניים / Eye Color* שחורות / Black חומות / Brown ירוקות / Green כחולות / Blue
האם אי פעם הורשעתם על רקע פלילי? / Criminal Record?* פירוט קצר על המקרה*
פרטי הורים ומצב משפחתי #7 שם מלא האב / Father's Name (First and Last)*
ארץ לידת האב / Father place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region*
אזרחות קודמת / Previous Nationality / Region
שם מלא האם / Mothers Name (First and Last)*
ארץ לידת האם / Mother place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות / Nationality / Region
אזרחות קודמת / Previous Nationality / Region*
מצב משפחתי / Applicant’s marital status* שם בן / בת זוג / Partner Name*
ארץ לידה / Place of birth* Aghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island -- Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Fiji Finland Former Yugoslav Republic of Macedonia France French Guiana French Polynesia French Southern Territories -- Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Marianas Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda São Tomé and Príncipe Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe
אזרחות בן / בת הזוג / Spouse Nationality / Region*
אזרחות קודמת בן / בת הזוג / Previous Nationality / Region
פרטי תעסוקה וצבא #7 תעסוקה / Present Occupation* שכיר / Employee עצמאי / Self Employed אבטלה / Unemployed גמלאות / Retired סטודנט/תלמיד / Student
שם החברה / מקום עבודה / Employer Name / Business*
כתובת עבודה / עסק / Business Address*
האם גויסתם לצה"ל / Have you been recruited to the IDF? מהו סוג התפקיד שהיה לכם ? / what was your military role?* לוחם / Fighter תומך לחימה / Combat Support גו'בניק / Other
דרגת שחרור / Rank when discharged* טוראי / Private רב"ט / corporal סמל / sergeant סמ"ר / staff sergeant דרגת נגד / non-commissioned officer דרגת קצין / officer
פרטי ביקור בהודו ומדינות שכנות #7 האם ביקרתם בהודו בעבר? / Did you visit India in the Past?* היכן שהיתם בהודו?
• הזינו כתובת / שם מלון באנגלית
• אם אינכם זוכרים, השאירו ריק
מספר הויזה ההודית הקודם שלכם
• הזינו את מספר הויזה ההודית שהייתה לכם
• אם אינכם יודעים, השאירו ריק
האם ביקרתם באחת ממדינות ה-SAARC בשלושת השנים האחרונות?* / Did you visit any restricted SAARC country in the past 3 years? • מדינות ה-SAARC הן:
אפגניסטן, בהוטן, פקיסטן, האיים המלדיביים, בנגלדש, סרי לנקה, נפאל.
באיזו מדינה ביקרתם ?* אפגניסטן בהוטן פקיסטן האיים המלדיביים בנגלדש סרי לנקה נפאל
תאריך הביקור* האם דחו את בקשתכם להיכנס למדינה כלשהי?* / Were you denied an entry to a country? • דחיית בקשה לויזה או סילוק ממדינה מסוימת
פירוט קצר על הסירוב*