a. Please read all the instructions carefully before completing this form.

b. All particulars must be fully stated in block letters.

c. Incorrect or incomplete statements may result in delay or refusal of the application. If any error is discovered after status has been granted the applicant status may be revoked.

d. Applicants may use the services of a local attorney or accountant when processing the application.

PERSONAL INFORMATION

__________________________________________________________________
1. FULL NAME


___________________________________________________
2. NAME AT BIRTH (IF DIFFERENT FROM ABOVE)



3. DATE OF BIRTH
DAY       MONTH       YEAR



__________________________________________________________________
4. PLACE & COUNTRY OF BIRTH



___________________________________________________
5. NATIONALITY


___________________________________________________
6. PERMANENT ADDRESS (IN FULL)

      _____________________________________
      (NUMBER)    "   (STREET)    "   (SUBURB OR VILLAGE)            


      _____________________________________
      (CITY)                                                      (COUNTRY)         


      _________________________
      (ZIP CODE)/(COUNTRY CODE)


___________________________________________________
7. INTENDED ADDRESS IN BELIZE


  

8.      PASSPORT NUMBER ______________      PLACE OF ISSUE_________________

         DATE ISSUED ________________              DATE OF EXPIRATION _____________

9.  PHONE # ___________________            10. FAX #_____________________

11.  E-MAIL ADDRESS___________________________

12.   MARITAL STATUS:      (i) SINGLE ‰       (ii)  MARRIED ‰

13.  SEX:            (i) MALE ‰                      (ii) FEMALE ‰

14. CONTACT INFORMATION OF AGENT IF APPLICATIONS IS PROCESSED
BY ONE: ______________________________________________________________

FAMILY INFORMATION 

14. DETAILS OF DEPENDENTS ACCOMPANYING APPLICANT TO BELIZE.
(ATTACH COPY OF ALL PASSPORT PAGES)

NAME

RELATIONSHIP TO APPLICANT

DATE OF
BIRTH

PLACE OF
BIRTH

NATIONALITY

16. IF YES, STATE THE ESTIMATED VALUE ________________________

17. WILL YOU OR YOUR DEPENDENTS IMPORT A
MEANS OF TRANSPORTATION INTO BELIZE?

YES        NO  

18. IF YES, STATE

TYPE   ________________________________________________________    

YEAR  ________________________________________________________

MAKE  ________________________________________________________

MODEL________________________________________________________



19. EDUCATION OF APPLICANT (NUMBER OF YEARS COMPLETED)

PRIMARY  ____________________      YEARS_____________

SECONDARY  ____________________       YEARS ________

SECONDARY  ____________________       YEARS ________

TERTIARY  ____________________    YEARS ______________

20. LANGUAGES SPOKEN (STATE PROFICIENCY)

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND
BELIEF THE PARTICULARS GIVEN IN THIS APPLICATION ARE CORRECT.

SIGNATURE:  _____________________   

DAY       MONTH       YEAR