‫بسمه تعالی‬
Form #103
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دی سی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
2209 WISCONSIN AVENUE N.W., WASHINGTON, DC 20007, TEL: (202) 965-4990-4, FAX: (202) 965-1073
WWW.DAFTAR.ORG, E-MAIL ADDRESS: [email protected]
Requirements for Approved Applicants to Obtain an Entry Visa to Iran
Please read and adhere to the following statements very carefully. Failure to
follow the guidelines may result in the rejection of your visa request.
1- Fill out the attached “Visa Application Form.” Answer all questions completely.
Complete addresses, names, phone numbers, etc. must be written. If a question is not
applicable to you, write N/A. Failure to answer all questions completely may result in
denial of your visa request.
2- The applicant’s valid passport. The Passport must be valid for at least six months.
3- One passport picture. The Passport picture must be of professional quality, 2” by 2”,
white background, front face, and been taken within the last six months. Do not send
photocopied pictures. Pictures of Muslim female applicants of age nine and above must
be with Islamic head cover (hejab), and Islamic dress code. Please do not glue or staple
the picture to the application form. You can clip it to the passport, or the application
form. Write your name lightly on the back of the picture.
4- For visa fees, please refer to the list below, our website, or call our office. All fees
can be in one money order or cashier check, and must be in the form of U.S. dollars, and
must be made to the order of “Embassy of Pakistan”. For U.S., the shipping fee is $30;
for outside U.S. $40. No prepaid envelope is accepted.
5-You must allow enough time for your request to be processed. We cannot be
responsible for reservations, or tickets that are paid for in advance.
6- Expedited service is available only if you add $58 for each passport to the visa fee.
This is in additional to the fee for shipping. You must use a red magic marker to write
clearly and noticeably on the outside of the carrier service envelope, front and back,
“Please Expedite.” This will prevent your package to be mixed with other packages,
and will help us identify it easily. Expedited service, if all documents are complete, will
be processed as soon as possible.
REV. (11-06-14)
‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دی سی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
2209 WISCONSIN AVENUE N.W., WASHINGTON, DC 20007, TEL: (202) 965-4990-4, FAX: (202) 965-1073
WWW.DAFTAR.ORG, E-MAIL ADDRESS: [email protected]
Visa Fees:
For visa fees for attending conferences, lectures, meetings, activities, etc., (excluding
purely tourism or pilgrimage), please refer to column 1. These fees are for single entry
visa. Double entry visas must specifically be approved by our Foreign Ministry and have
different fees.
For tourism and pilgrimage visa fees, please refer to column 2, and 3. For other visa types
and countries not listed, please inquire.
Country
1- Afghanistan
2- Armenia
3- Australia
4- Austria
5- Bangladesh
6- Canada
7- China
8- Croatia
9- Egypt
10- France
11- Germany
12- Greece
13- India
14-India
15- Iraq
16- Japan
17- Kuwait
18- Lebanon
Fee
conferences,
lectures,
meetings,
activities,etc.
Fee
(one entry)
tourism and
pilgrimage
Fee
(Double entry)
tourism and
pilgrimage
1
2
3
$120
$25
$120
$90
$45
$90
$120
$45
$30
$90
$90
$90
$60
$..
$40
$75
$60
$45
$60
Add $30 for
each
accompany.
$15
$105
$75
$40
$75
$75
$40
$15
$75
$75
$75
$45
$15
$15
$60
$25
$15
$90
Country
Fee
conferences,
lectures,
meetings,
activities,etc.
Fee
(one entry)
tourism and
pilgrimage
Fee
(Double entry)
tourism and
pilgrimage
1
2
3
19- Mexico
$50
$45
$65
20- Netherlands
21- New Zealand
22- Nicaragua
23- Nigeria
24- Norway
25- Pakistan
26-Pakistan
27- Peru
28- Philippines
29- Russia
30- Tanzania
31-Tanzania
32- U.K
33- U.S.A.
34- Venezuela
35- Vietnam
$90
$150
$45
$65
$90
$45
$25
$75
$65
$105
$75
$30
$300
$120
$60
$45
$75
$120
$30
$60
$75
$40
$25
$60
$60
$60
$60
$30
$265
$90
$30
$30
$110
$175
$45
$90
$110
$55
$40
$90
$90
$90
$90
$45
$400
$135
$45
$45
Add $45 for
each
accompany.
$25
$155
$110
$55
$110
$110
$55
$15
$110
$110
$110
$65
$25
$25
$90
$40
$25
(Rev.12-08-2014)
‫بسمه تعالی‬
‫دفتر حفاظت منافع جمهوری اسالمی ایران – واشنگتن دی سی‬
EMBASSY OF PAKISTAN
INTERESTS SECTION OF THE ISLAMIC REPUBLIC OF IRAN
2209 WISCONSIN AVENUE N.W., WASHINGTON, DC 20007, TEL: (202) 965-4990-4, FAX: (202) 965-1073
WWW.DAFTAR.ORG, E-MAIL ADDRESS: [email protected]
PLEASE CLIP
YOUR
PICTURE HERE.
DO NOT GLUE OR
STAPLE THE
PICTURE.
PUT YOUR NAME
ON THE BACK OF
THE PICTURE.
‫پرسشنامه درخواست روادید‬
VISA APPLICATION
‫مخصوص قسمت اداری‬
FOR OFFICE USE ONLY
‫مدت اقامت‬
‫نوع روادید‬
‫شماره روادید‬
‫مجوز و تاریخ صدور‬
‫مدت اعتبار‬
‫تاریخ صدور‬
ALL QUESTIONS ON THIS FORM MUST BE ANSWERED FOR THE APPLICATION TO BE CONSIDERED
PLEASE PRINT CLEARLY IN ENGLISH, USING THE INFORMATION IN YOUR PASSPORT
FIRST NAME:
: ‫ نام‬OCCUPATION:
:‫نام خانوادگی‬
LAST NAME:
SEX:
MALE
‫زن‬
FEMALE
‫مرد‬
:‫جنسیت‬
:‫تاریخ و محل تولد‬
PLACE & DATE OF BIRTH:
PRESENT NATIONALITY:
:‫تابعیت فعلی‬
FORMER NATIONALITY:
:‫تابعیت قبلی‬
:‫نام پدر‬
FATHER’S NAME:
:‫تابعیت پدر‬
FATHER’S NATIONALITY:
:‫شغل‬
FORMER OCCUPATION:
:‫شغل قبلی‬
----------------------------------------------------------------------------------------------------: ‫نوع ویزای شما در کشور محل اقامت‬
YOUR VISA STATUS IN THE COUNTRY OF YOUR RESIDENCE:
:‫تحصیالت‬
EDUCATION:
:‫شماره گذرنامه‬
PASSPORT NO:
:‫تاریخ خاتمه اعتبار‬
EXPIRATION DATE:
MARITAL STATUS:
SINGLE
MARRIED
DIVORCED
‫متاهل‬
‫مجرد‬
: ‫وضعیت تاهل‬
‫مطلقه‬
IF MARRIED, NAME & NATIONALITYOF SPOUSE:
:‫ نام و تابعیت همسر‬،‫در صورت تاهل‬
:‫نوع روادید درخواستی‬
TYPE OF VISA REQUESTED:
TOURISM/‫جهانگردی‬
PILGRIMAGE/‫زیارتی‬
NUMBER OF ENTRIES REQUESTED:
SINGLE
OFFICIAL/‫ورود‬
DOUBLE
PURPOSE OF VISIT TO THE I.R. OF IRAN:
DATE OF DEPARTURE FROM THE COUNTRY OF RESIDENCE:
JOURNALISM/‫خبرنگاری‬
DIPLOMATIC/‫سیاسی‬
OTHER/‫متفرقه‬
:‫دفعات ورود درخواستی به ایران‬
‫دوبار‬
‫یکبار‬
:‫منظور از مسافرت به ایران‬
:‫تاریخ حرکت از کشور محل اقامت‬
DATE OF ENTRY TO THE I.R. OF IRAN:
:‫تاریخ ورود به ایران‬
DURATION OF STAY IN THE I.R. OF IRAN:
:‫مدت اقامت در ایران‬
HAVE YOU EVER APPLIED FOR VISA TO THE I.R. OF IRAN?
YES
NO, IF YES, WHEN & WHERE?
HAS YOUR VISA APPLICATION TO THE I.R. OF IRAN EVER BEEN REJECTED?
YES
‫ کی و کجا؟‬،‫ اگر بله‬،‫خیر‬
‫بله‬
:‫ تاریخ آن را اعالم نمائید‬،‫درصورت مخالفت قبلی با صدور روادید‬
NO, IF YES, WHEN & WHY?
HAVE YOU EVER VISITED THE I.R. OF IRAN BEFORE?
YES
‫آیا تاکنون برای مسافرت به ایران درخواست روادید کرده اید؟‬
NO, IF YES, WHEN & WHY?
LIST ALL CITIES IN THE I.R. OF IRAN YOU HAVE VISITED:
‫آیا تاکنون به ایران مسافرت کرده اید؟‬
:‫ تاریخ وعلت آن را توضیح دهید‬،‫ اگر بله‬،‫خیر‬
‫بله‬
:‫شهرهائی را که در ایران از آنها دیدن کرده اید را نام ببرید‬
(Rev.11-06-2014)
‫آیا قصد کار خبرنگاری و یا تحقیقاتی در ایران دارید؟‬
WILL YOU BE ACTIVE IN JOURNALISTIC AFFAIRS OR SCIENTIFIC RESEARCH IN THE I.R. OF IRAN?
YES
‫خیر‬
NO
:‫ بنویسد‬،‫نام اشخاصی که قصد مالقات با آنها را دارید‬
NAME OF THE INDIVIDUALS YOU PLAN TO MEET WITH IN THE I.R. OF IRAN:
:‫آدرس و تلفن دو تن از دوستان یا بستگان خود را در ایران بنویسید‬
PLEASE ENTER THE NAME & ADDRESS OF TWO OF YOUR FRIENDS OR RELATIVES IN IRAN:
1- NAME:
‫بله‬
TEL:
ADDRESS:
2- NAME:
TEL:
ADDRESS:
:‫کشورهائی را که تاکنون از آنها دیدن کرده اید را نام ببرید‬
LIST ALL COUNTRIES YOU HAVE VISITED:
LIST ALL COUNTRIES YOU STAYED MORE THAN SIX MONTHS:
:‫ آن کشورها را نام ببرید ودلیل آن را توضیح دهید‬،‫درصورتی که توقف بیش از شش ماه در کشوری داشته اید‬
HAVE YOU EVER HAD ANY HISTORY OF ARRESTS OR CONVICTIONS IN ANY COUNTRY? IF YES, PLEASE EXPLAIN:
HAVE YOU EVER BEEN INFECTED BY ANY CONTAGIOUS DISEASES? IF YES, PLEASE EXPLAIN:
YOUR ADDRESS & TELEPHONE NUMBER IN THE I.R. OF
‫آیا تاکنون به بیماری مزمنی که میتواند سالمتی جامعه را به خطر بیندازد‬
:‫ لطفاً توضیح بدهید‬،‫مبتال شده اید؟ اگر بله‬
IRAN:
:‫را بنویسید‬
STREET:
CITY:
STATE:
ZIP CODE:
‫آیا تاکنون در هیچ کشوری سابقه کیفری و دستگیری‬
:‫ لطفاً توضیح دهید‬،‫داشته اید؟ اگر بله‬
TEL: (
)
‫آدرس و تلفن محل اقامت خود در ایران‬
:‫خیابان‬
:‫شهر‬
-
:‫تلفن‬
:‫آدرس و تلفن محل کار‬
BUSINESS ADDRESS (NOT P.O. BOX):
STREET:
CITY:
STATE:
ZIP CODE:
TEL: (
)
:‫آدرس پستی‬
MAILING ADDRESS (NOT P.O. BOX):
STREET:
CITY:
STATE:
ZIP CODE:
TEL: (
)
-
E-MAIL :
I UNDERTAKE TO OBSERVE, DURING MY STAY IN THE I.R. OF IRAN, ALL THE LAWS AND REGULATIONS
APPLICABLE TO FOREIGN NATIONALS AND I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND
CORRECT.
.‫ کلیه قوانین مربوطه را رعایت بنمایم و کلیه اطالعات فوق صحیح میباشد‬،‫اینجانب تعهد میکنم که در طول اقامتم در جمهوری اسالمی ایران‬
APPLICANT’S SIGNATURE: ____________________________________
DATE: ______________________________
(Rev.11-06-2014)