APPLICATION FORM FOR VISACONSULATE OF CHILE TO CAIRO

ARAB REPUBLIC OF EGYPT1. LAST NAME (As shown in your passport)

Sakr2. FIRST AND MIDDLE NAME (As shown in your passport)

Mohamed

3. FULL NAME (Please write your full name, as appears in your passport)

Mohamed Kamel Abdelhafez Hussien Sakr

4. SEX

.......MALE

4. DATE OF BIRTH ( dd / mm / yyyy )

1/11/19815. PLACE OF BIRTH (City and Country)

Cairo,Egypt

6. NATIONAL ID. CARD NUMBER

28111010113514

7. PASSPORT NUMBER

A11495061

8. PLACE AND DATE OF ISSUANCE

11/2/2014

9. EXPIRATION DATE

10/2/2021

10. NATIONALITY

Egyptian

12.HOME ADDRESS (Street, Number, Apartment, District, City, Governorate, Country)

Tayaran St, 1 , Apartment 10, District 7, Nasr City, Cairo, Egypt.13. HOME PHONE NUMBER

+202 22624775

14. MARITAL STATUS

Married15. PROFESSION

Sales Manager16. OCCUPATION OR ACTIVITY

Sales Manager

17. EMPLOYER’S NAME

Aura Trading Agencies18. EMPLOYER’S ADDRESS

Mohamed Zaki barakat St, 88 , District 8, Nasr City, Cairo, Egypt

19. EMPLOYER’S PHONE NUMBER

+202 22671135120. IF SELF EMPLOYED, PLEASE SPECIFY

21. COLOR OF HAIR

Black22. COLOR OF EYES

Brown

23. HEIGHT (Cm.)

167 cm24. WEIGHT (Kg.)

68 kg

25. PARTICULAR FEATURES

26. COMPLETE NAME OF THE FATHER (IF DECEASED, PLEASE SPECIFY)

Kamel Abdelhafez Hussien Sakr27. NATIONALITY OF THE FATHER

Egyptian

28. COUNTRY OF RESIDENCE OF THE FATHER

Egypt29. ADDRESS AND TELEPHONE NUMBER OF THE FATHER

Dawood Barakat St, 6, Flat 8 , District 7, Nasr City, Cairo, Egypt

30. COMPLETE NAME OF THE MOTHER (If deceased, please specify)

Reda Mohamed Youssef Youssef31. NATIONALITY OF THE MOTHER

Egyptian

32. COUNTRY OF RESIDENCE OF THE MOTHER

Egypt33. ADDRESS AND TELEPHONE NUMBER OF THE MOTHER

Dawood Barakat St, 6, Flat 8 , District 7, Nasr City, Cairo, Egypt

34. FULL NAME OF THE APPLICANT’S SPOUSE

Ximena Andrea Fierro Perez35. SPOUSE DATE OF BIRTH

18/2/1986

36. SPOUSE PLACE OF BIRTH (City and Country)

Las Condes Santiago37. SPOUSE NATIONALITY

Chilean

38. CHILDREN NAMES

Yassin Mohamed Kamel Abdelhafez Fierro

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39. CHILDREN NATIONALITIES

Chilean---------------------------------------------------------

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40. CHILDREN BIRTHDATES

18/6/2014------------------------------------------

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41. NAME OF YOUR HOTEL OR HOST IN CHILE

Santiago Metro Santa Lucia 42. ADDRESS OF YOUR HOTEL OR HOST IN CHILE (Street, Number, Apartment, City)

Granados 535, Downtown Santiago, 8330125 Santiago, Chile

Apartamentos43. HOTEL OR HOST TELEPHONE NUMBERS

+5697260275044. HOTEL OR HOST FAX 45. HOTEL OR HOST E-MAIL

46. INTENDED DATE OF ARRIVAL TO CHILE

4th November,201547. FLIGHT NUMBER 48. INTENDED DATE OF DEPARTURE FROM CHILE

4th Jan, 201649. FLIGHT NUMBER

50. HAVE YOU EVER APPLY FOR A VISA TO VISIT CHILE?

....√.... YES

51. YEAR OF APPLICATION

201352. WHERE DID YOU SUBMIT THIS APPLICATION?

The Chilean Embassy in Cairo

53. WAS YOUR VISA APPLICATION APPROVED?

....√.... YES

54. DID YOU VISIT CHILE?

.....√... YES

55. PLEASE, STATE DATE AND DURATION OF THAT VISIT

From 3-7-2013 to 10-10 2013

56. IS ANY OF THE FOLLOWING PERSONS IN CHILE? ( Yes / No )

FATHER.......... MOTHER.......... BROTHERS.......... SISTERS......... SPOUSE..√........ FIANCÉE........ OTHER √

(Specify).......Son............................................

57. PLEASE, STATE THE LIST OF THE COUNTRIES YOU HAVE VISITED ON THE LAST FIVE YEARS:COUNTRY:

Chile-----------------------------------------------------------------------------------------------------------------------------------

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YEAR OF VISIT:

2013------------------------------------------------------------------------------------------

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58. AFFIDAVIT:

I declare that I am aware that during my stay in Chile I may not carry out gainful activities nor intervene in its internal policy or in acts against its Political Constitution or Laws, Decrees and other provisions applicable in its territory and promise, during my stay in Chile not to apply for a change of my status of tourist. I further declare that all particulars contained in this Application are true.

---------15th September,2015------------------------- -----------Mohamed Kamel Abdelhafez Sakr------- DATE SIGNATURE