BoliviaVisa .pdf

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Ministerio de Relaciones Exteriores
Viceministerio de Gestión Institucional y Consular
Direccion General de Asuntos Consulares
www.rree.gob.bo

Ministerio de Gobierno
Direccion General de Migracion
www.migracion.gob.bo

Nro.: RREE-VC- 98129

DECLARACION JURADA DE SOLICITUD DE VISA
SWORN STATEMENT FOR VISA APPLICATION
TIPO DE VISA REQUERIDA/TYPE OF VISA REQUESTED

Visas de Turismo, conforme a normativa vigente y reciprocidad

Primer Apellido/Surname 1

Segundo Apellido/Surname 2

Otros apellidos/Other Surnames

Soares
Primer nombre/First name

Segundo nombre/Middle name

Dubinsky

Sexo/Sex

Dee

Lugar y fecha de nacimiento
Place and date of birth

Masculino

Nacionalidad/Nationality

Estado Civil/Marital status

INDIA

Soltero

ARABIA SAUDITA
Buraidah
23/06/1990
Numero de documento de identificacion/
National Identification Number

Ocupacion actual/Present occupation

Staffing Specialist

J6282821
Clase y numero de pasaporte/Passport type and number:

CORRIENTE

Pais donde se emitio/Issuing Country

j6282821

INDIA

Lugar de emision/Place of issuance:
Ciudad:

Panaji

Pais:

INDIA

Fecha de emision/issuing date:

Goa

21/06/2011
Fecha de expiracion/Expiration date:

20/06/2021
Telefono de su residencia/Home phone number:
Telefono donde trabaja/Work phone number:
Telefono Celular/Mobile:

+919049007816

Direccion electronica/Email address:

dubinskysoares@gmail.com

No

Solicito visa anteriormente?/Have you applied before for a visa?
Donde?/Where?
Fecha/Date:

Cuanto tiempo en dias desea permanecer en Bolivia? / How
long indays you want to stay to stay in Bolivia?

10
Cual es su principal destino en Bolivia? / What is your
main destination in Bolivia?

Tiene familiares en Bolivia?/Do you have
relatives in Bolivia?

La Paz/Abel Iturralde/Ixiamas

Nombre completo/Full name:

No

Direccion/Street address:
Ciudad/City:
Telefono/telephone number::
Persona(s) de contacto en caso de mergencia/Emergency contact
Nombre completo/Full name:

Direccion donde trabaja/Work address:

Antonio Augusto Soares
Nombre completo/Full name:

Calle/Street address:

F-12, Garden View Complex, Ponda, Goa

Diana Virgincia Mendonca

Ciudad/City:

ponda

Fecha de nacimiento/Date of birth:

Estado o Departamento/State or Province

11/04/1953 0:00:00

Goa

Direccion donde vive/Home address:

Codigo Posta/Postal Code:

401401

F-1, Garden View Complex, Ponda, Goa

Pais/Country:

India

Opp. Municipal Garden

Calle/Street address:

Telefono/Telephone number:

+919923487030

Estado o Departamento/State of Province

Goa
Codigo Postal/Postal Code:

403401
INDIA

Pais/Country:
Lugar de la solicitud
Place of the application:

Buenos aires

Dia/Day

Mes/Month

2

Año/Year

5

2.017

**Declaro que toda la informacion registrada en este documento es veridica. Conozco que la Declaración Jurada con
informacion falsa es pasible a sanciones de acuerdo a la Ley./I declare that all information recorded in this document is true
and correct. I am aware that a Sworn Statement with fraudulent information is liable to penalties under the law

Firma del solicitante
Signature of the applicant

Fecha de registro 02/05/2017 16:51:00

Firma de la autoridad consular
Signature of Consular Authority

Fecha de impresion: 02/05/2017

Este formulario tiene una validez de 15 días a partir de su fecha de registro / This form is valid for 15 days from the date of
registration


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