‫ﺭﻗﻢ ﺍﻻﺳﺘﻤــــﺎﺭﺓ ‪..........................

:‬‬
‫ﺗﺎﺭﻳﺦ ﺗﻨﻈﻴﻤﻬــــﺎ ‪..........................:‬‬ ‫ﺟﻣﻬﻭﺭﻳﺔ ﺍﻟﻌﺭﺍﻕ‬
‫ﺭﻗﻢ ﺳﻤﺔ ﺍﻟﺪﺧﻮﻝ ‪..........................:‬‬
‫ﺗﺎﺭﻳﺦ ﻣﻨﺢ ﺍﻟﺴﻤﺔ ‪..........................:‬‬
‫ﻭﺯﺍﺭﺓ ﺍﻟﺩﺍﺧﻠﻳﺔ‬
‫ﺗﺎﺭﻳﺦ ﺍﻟــــﺪﺧﻮﻝ ‪..........................:‬‬ ‫ﺍﻟﻣﺩﻳﺭﻳﺔ ﺍﻟﻌﺎﻣﺔ ﻟﻠﺳﻔﺭ ﻭﺍﻟﺟﻧﺳﻳﺔ‬
‫ﻣﺩﻳﺭﻳﺔ ﺍﻻﻗﺎﻣﺔ‬

‫‪Add‬‬
‫‪image‬‬
‫ﺻﺤﻴﻔﺔ ﺍﻋﻤﺎﻝ ﺍﻻﺟﻨﺒﻲ ﻟﻐﺮﺽ ﻁﻠﺐ ﺳﻤﺔ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻻﺭﺍﺿﻲ ﺍﻟﻌﺮﺍﻗﻴﺔ‬
‫‪Visa Application Form for Visiting the Republic of Iraq‬‬
‫‪Note: You must fill in all fields‬‬ ‫ﻣــــﻼﺣــــﻈــــﺔ ‪ :‬ﻳﺠﺐ ﻣــﻞء ﻛـــﺎﻓــﺔ ﺍﻟــﺤــﻘـــﻮﻝ‬

‫‪Name & Surname‬‬ ‫‪:‬‬ ‫ﺍﻷﺳﻢ ﺍﻟﻜﺎﻣﻞ ﻭﺍﻟﺸﻬﺮﺓ ‪:‬‬

‫‪Religion‬‬ ‫‪:‬‬ ‫ﺍﻟﺪﻳﺎﻧﺔ ‪:‬‬ ‫‪male‬‬ ‫ﺫﻛﺮ‬ ‫‪female‬‬ ‫ﺃﻧﺜﻰ‬ ‫ﺍﻟﺠﻨﺲ‬
‫‪Original Nationality :‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ﺍﻻﺻﻠﻴﺔ ‪:‬‬ ‫‪Current Nationality :‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ﺍﻟﺤﺎﻟﻴﺔ ‪:‬‬
‫‪Country of birth‬‬ ‫‪:‬‬ ‫‪:‬‬ ‫ﺑﻠﺪ ﺍﻟﺘﻮﻟـــــــــﺪ‬ ‫‪Date of Birth‬‬ ‫‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎﺭﻳــﺦ ﺍﻟـﻮﻻﺩﺓ ‪:‬‬
‫‪Previous Occupation :‬‬ ‫ﺍﻟﻤﻬﻨﺔ ﺍﻟﺴــــﺎﺑﻘﺔ ‪:‬‬ ‫‪Current Occupation :‬‬ ‫ﺍﻟﻤﻬﻨﺔ ﺍﻟﺤــﺎﻟﻴﺔ ‪:‬‬
‫‪Address of his Residence in his Country :‬‬ ‫ﺍﻟﻌﻨﻮﺍﻥ ﻓﻲ ﺑﻠﺪﻩ ‪:‬‬

‫‪Phone Number:‬‬ ‫ﺭﻗـﻢ ﺍﻟـﻬﺎﺗـﻒ‪:‬‬

‫‪Email Address:‬‬ ‫ﺍﻟﺒﺮﻳﺪ ﺍﻻﻟﻴﻜﺘﺮﻭﻧﻲ‪:‬‬

‫‪Nationality :‬‬ ‫ﺍﻟﺠﻨﺴﻴـــﺔ ‪:‬‬ ‫‪Wif's / Husband's name :‬‬ ‫ﺃﺳﻢ ﺍﻟﺰﻭﺝ‪ /‬ﺍﻟﺰﻭﺟﺔ ‪:‬‬
‫‪/‬‬ ‫‪/‬‬
‫‪Occupation :‬‬ ‫ﺍﻟﻤﻬﻨــــــﺔ ‪:‬‬ ‫‪Place & date of birth‬‬ ‫‪:‬‬ ‫ﻣﺤﻞ ﻭﺗﺎﺭﻳﺦ ﺍﻟﺘﻮﻟﺪ ‪:‬‬
‫‪Place of Husbands/Wife's work:‬‬ ‫ﻣﺤﻞ ﻋﻤﻞ ﺍﻟﺰﻭﺝ‪/‬ﺍﻟﺰﻭﺟﺔ ‪:‬‬

‫‪Issuing Country :‬‬ ‫ﺑﻠﺪ ﺃﺻﺪﺍﺭ ﺍﻟﺠﻮﺍﺯ ‪:‬‬ ‫‪Passport Number‬‬ ‫‪:‬‬ ‫ﺭﻗﻢ ﺟﻮﺍﺯ ﺍﻟﺴﻔــــــﺮ‪:‬‬
‫‪Exp. Passport‬‬ ‫‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪ Date of Issue‬ﺗﺎﺭﻳﺦ ﺍﻧﺘﻬﺎء ﺍﻟﺠﻮﺍﺯ ‪:‬‬ ‫‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗـــــــﺎﺭﻳﺦ ﺍﻻﺻﺪﺍﺭ ‪:‬‬
‫‪Accompanied Persons :‬‬ ‫ﺍﻟﻤﺮﺍﻓﻘﻮﻥ ﻓﻲ ﺍﻟﺠـــــــﻮﺍﺯ ‪:‬‬

‫‪Profession‬‬ ‫‪:‬‬ ‫ﺍﻻﺧﺘﺼــــــــــــﺎﺹ ‪:‬‬ ‫‪Certificates‬‬ ‫‪:‬‬ ‫ﺍﻟـﺸﻬـــﺎﺩﺓ ﺍﻟــــﻌﻠﻤﻴﺔ ‪:‬‬

‫‪Place of issuing Certificates :‬‬ ‫ﺟﻬﺔ ﻣﻨﺢ ﺍﻟــــﺸﻬﺎﺩﺓ ‪:‬‬
‫‪Date of Issuing Certificates‬‬ ‫‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺤﺼﻮﻝ ﻋﻠﻰ ﺍﻟــــﺸﻬﺎﺩﺓ ‪:‬‬

‫‪Place of Issuing Visa :‬‬ ‫ﺍﻟﺠﻬﺔ ﺍﻟﻤﺎﻧﺤﺔ ﻟﻠﺴﻤﺔ ‪:‬‬

‫‪Place Proceed from :‬‬ ‫ﺍﻟﺠﻬﺔ ﺍﻟﻘﺎﺩﻡ ﻣﻨﻬــــــﺎ ‪:‬‬
‫‪Place of Entering‬‬ ‫‪:‬‬ ‫ﺍﻟﻤﻨﻔﺬ ﺍﻟﺤﺪﻭﺩﻱ ﻟﻠﺪﺧﻮﻝ ‪:‬‬
‫‪Purpose of Entering Iraq :‬‬ ‫ﺍﻟﻐﺎﻳﺔ ﻣﻦ ﺩﺧﻮﻝ ﺍﻟﻌﺮﺍﻕ‪:‬‬
‫‪Expected Time of residence in Iraq :‬‬ ‫ﻣﺪﺓ ﺍﻟﺒﻘﺎء ﺍﻟﻤﺘﻮﻗﻌﺔ ﻓﻲ ﺍﻟﻌﺮﺍﻕ‪:‬‬

‫‪Full Address for staying in Iraq :‬‬ ‫ﺍﻟــــﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻟﻼﻗﺎﻣﺔ ﻓﻲ ﺍﻟــــﻌﺮﺍﻕ‪:‬‬
‫‪Full Address for place of work in Iraq :‬‬ ‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻟﻤﻮﻗﻊ ﺍﻟﻌﻤﻞ ﻓﻲ ﺍﻟﻌﺮﺍﻕ‪:‬‬
‫‪Name of contracting firm in Iraq :‬‬ ‫ﺃﺳﻢ ﺍﻟـﺠﻬﺔ ﺍﻟﻤﺘﻌﺎﻗﺪ ﻣﻌﻬﺎ ﻓﻲ ﺍﻟـــﻌﺮﺍﻕ ‪:‬‬

‫‪1‬‬
‫‪Number of Previous Entering to Iraq :‬‬ ‫ﻋﺪﺩ ﻣﺮﺍﺕ ﺍﻟﺪﺧﻮﻝ ﺍﻟﺴﺎﺑﻘﺔ ﺍﻟﻰ ﺍﻟﻌﺮﺍﻕ‪:‬‬
‫‪Date of the last pervious Entry to Iraq‬‬ ‫‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫‪:‬‬ ‫ﺗﺎﺭﻳﺦ ﺃﺧـــﺮ ﺩﺧـــﻮﻝ ﺳﺎﺑﻖ ﻟﻠﻌﺮﺍﻕ‬
‫‪Previous Occupation in Iraq :‬‬ ‫ﺍﻻﻋﻤﺎﻝ ﺍﻟﺘﻲ ﻣﺎﺭﺳﻬﺎ ﺳﺎﺑﻘﺎ ﻓﻲ ﺍﻟﻌﺮﺍﻕ‪:‬‬
‫‪Places of Precious Residence in Iraq :‬‬ ‫ﺍﻻﻣﺎﻛﻦ ﺍﻟﺘﻲ ﺃﻗﺎﻡ ﺃﻭ ﺍﺗﺨﺬﻫﺎ ﻣﻘﺮﺍ ﻟﻪ ﻓﻲ ﺍﻟﻌﺮﺍﻕ ‪:‬‬
‫‪Have you served in Diplomatic or Commercial service in Iraq & when :‬‬ ‫ﻫﻞ ﺳﺒﻖ ﻟﻪ ﺍﻟﻌﻤﻞ ﻓﻲ ﺍﻟﻌﺮﺍﻕ ﻓﻲ ﺍﻟﺴﻠﻚ ﺍﻟﺪﺑﻠﻮﻣﺎﺳﻲ ﺍﻭ ﺍﻟﺘﺠﺎﺭﻱ ‪:‬‬

‫‪Have you been relegated from Iraq before & when :‬‬ ‫ﻫﻞ ﺗﻢ ﺍﺑﻌﺎﺩﻙ ﻋﻦ ﺍﻟﻌﺮﺍﻕ ﺳﺎﺑﻘﺎ ﻭﻣﺘﻰ ‪:‬‬

‫‪Children's Name, Age & Occupation‬‬ ‫ﺃﺳﻤﺎء ﺍﻷﻭﻻﺩ ﻭﺍﻋﻤﺎﺭﻫﻢ ﻭﻣﻬﻨﻬﻢ‬

‫ﺍﻟﻤﻬﻨﺔ ﻭﻣﻜﺎﻥ ﺍﻟﻌﻤﻞ‪Occupation/‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﻮﻟﺪ‪Date of Birth/‬‬ ‫ﺍﻷﺳﻢ ‪Name/‬‬
‫‪/‬‬ ‫‪/‬‬ ‫‪1‬‬

‫‪/‬‬ ‫‪/‬‬ ‫‪2‬‬

‫‪/‬‬ ‫‪/‬‬ ‫‪3‬‬

‫‪Countries Visited & Worked in‬‬ ‫ﺍﻟﺪﻭﻝ ﺍﻟﺘﻲ ﺯﺍﺭﻫﺎ ﺍﻭ ﻋﻤﻞ ﻓﻴﻬﺎ‬
‫ﺗﺎﺭﻳﺦ ﺍﻟﻌﻤﻞ ﺍﻭ ﺍﻟﺰﻳﺎﺭﺓ ‪Date of Work & Visited/‬‬ ‫ﻧﻮﻉ ﺍﻟﻌﻤﻞ ‪Kind of Work/‬‬ ‫ﺃﺳﻢ ﺍﻟﺪﻭﻟﺔ‪Name of Country/‬‬
‫‪/‬‬ ‫‪/‬‬ ‫‪1‬‬

‫‪/‬‬ ‫‪/‬‬ ‫‪2‬‬

‫‪/‬‬ ‫‪/‬‬ ‫‪3‬‬

‫‪References & their Adders in Iraq‬‬ ‫ﺍﻻﺷﺨﺎﺹ ﺫﻭﻱ ﺍﻟﻌﻼﻗﺔ ﺑﻬﻢ ﻓﻲ ﺍﻟﻌﺮﺍﻕ ﻭﻋﻨﺎﻭﻳﻨﻬﻢ‬
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻭﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ ‪Full Address & phone Number /‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ‪Nationality/‬‬ ‫ﺍﻷﺳﻢ ﺍﻟﻜﺎﻣﻞ‪Full Name/‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬

‫ﺗﻌﻬﺪ ﺍﻟﻄﺮﻑ ﺍﻟﻌﺮﺍﻗﻲ ﻋﻦ ﺍﻻﺟﻨﺒﻲ ﺃﻭ ﺍﻟﻌﺮﺑﻲ‬

‫ﺍﻷﺳﻢ ‪:‬‬
‫ﺍﻟﺘﻮﻗﻴﻊ ‪: Signatuer /‬‬
‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ﻭﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ ‪:‬‬
‫‪/‬‬ ‫‪/‬‬ ‫‪:‬‬ ‫ﺍﻟﺘﺎﺭﻳﺦ ‪Date /‬‬

‫ﺍﻟﻤﻬﻨﺔ ‪:‬‬

‫‪NOTE:‬‬ ‫ﻣﻼﺣﻈﺔ ‪:‬‬

‫‪*A person is legally responsible in case of give false‬‬ ‫* ﻳﺘﺤﻤﻞ ﺃﻱ ﺷﺨﺺ ﻳﺪﻟﻲ ﺑﻤﻌﻠﻮﻣﺎﺕ ﻏﻴﺮ ﺻﺤﻴﺤﺔ ﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‪.‬‬
‫‪information .‬‬ ‫* ﻳﺘﻢ ﺟﻠﺐ ﺍﻟﻤﺴﺘﻤﺴﻜﺎﺕ ﺍﻟﺨﺎﺻﺔ ﺑﻤﻨﺢ ﺍﻟﺴﻤﺔ ﻭﻧﺴﺨﺔ ﻣﻠﻮﻧﺔ ﻣﻦ ﺟﻮﺍﺯ ﺍﻟﺴﻔﺮ‪.‬‬
‫‪*Color copy of valid passport and other documents‬‬
‫‪required for visa application .‬‬
‫ﺍﻟﺘﻮﻗﻴﻊ ‪: Signatuer /‬‬

‫‪/‬‬ ‫‪/‬‬ ‫‪:‬‬ ‫ﺍﻟﺘﺎﺭﻳﺦ ‪Date /‬‬

‫‪2‬‬ ‫) ‪þÿ 7 ( ' 9‬‬ ‫) ‪' D ' 3 * E ' 1‬‬ ‫‪/ P r i n t h&d&y F o‬‬