Embassy of the Islamic Republic of Iran

Refrence No (from iran):

Canberra, Australia

To fill out the following visa application form, please read all questions first, and then proceed to fill out the form using a blue or black ballpoint pen

1a. Mr / Mrs / Miss 10. Other countries you have visited:1b. First name

1c. Surname

1d. Former name

2a. Father’s name

2b.Grandfather's name(only for arabs)

3a. Date of birth / / 3b. Place of birth

4a. Passport number

4b. Passport type

4d. Passport issue place

4e. Passport issue date

5. Present nationality

5b.Former nationality

6a. Marital Status; Married / Single6b. If married, what is your spouse’s nationality

7a. Applicant’s occupation

7b. Employer’s name

7c. Business address

8a. Contact telephone numbers;Home: Work:

8b. Permanent address;Street address

Postal address

9a. Address of contact in Iran

9b. Contact telephone in Iran

11. Type of visa you requireTourist Other (please specify)Business PressPilgrimageDiplomaticTransit

12. Purpose of your visit

13. The duration of your stay in Iran Months Days

14. Date of departure from Australia / /15a. Approximate arrival date into Iran / /15b. Border of entry

16. Name of organizations / persons you intend to meet in Iran

17. Who covers your expenses whilst in Iran?

18. How much money do you intend to take to Iran?

(Name of currency)

19a. Have you been in Iran before?

19b. If yes, which cities have you visited and when?

20a. Has your visa application ever been rejected?

20b. If yes, when?

21.Have you obtained a visa for the next country you intend to visit?Yes / No

22. Please write the name and relationship of persons travelling with you

I declare that the above information is true and correct. I undertake to observe while in Iran all laws and regulations applicable to foreign nations.

Applicant’s Signature Date: / /