Last Name: *________________________________________
First Name: *________________________________________
Gender: * Male Female
Date of Birth * Day ____ Month ________ Year________
Place of Birth * ______________________________________
Birth Nationality * ____________________________________
Present Nationality: *_________________________________
Passport Number: *___________________________________
Place of Issue: *______________________________________
Date Issued: *_______________________________________
Date Expire: *________________________________________
Present Occupation: ________________________________
Company: ________________________________________
Current Home Address: *____________________________
________________________________________________
Mobile Phone: *___________________________________
Home Phone: *____________________________________
Email Address: *___________________________________
Purpose of Visit*
Tourist Official Diplomatic
Business Other (Please Specify) _____________
Arrival Date in Cambodia*
Day_____ Month______ Year _________
Exit Date in Cambodia*
Day_____ Month______ Year _________
Jan - Feb - Mar - Apr
May - Jun - Jul - Aug
Sep – Oct – Nov - Dec
Jan - Feb - Mar - Apr
May - Jun - Jul - Aug
Sep – Oct – Nov - Dec
VISA APPLICATION FORM
Point of Entry: * ___________________________________
Means of Transportation: *___________________________
Address during the visit: * ___________________________
_________________________________________________
Point of Exit: *_____________________________________
Means of Transportation: *__________________________
Address during the visit: *____________________________
________________________________________________
First trip to Cambodia: Yes No
Travelling on group tour: Yes No
Tour Company: * __________________________________
FOR MAILING VISA REQUEST
Send it to:
Royal Embassy of Cambodia (Visa Application)
4530 16
th
Street N.W.
Washington D.C. 20011
Please send it through USPS – Priority Mail Envelope – with TRACKING
NUMBER.
For (send back) INSERT PREPAID USPS return self-address PRIORITY MAIL
envelope with a TRACKING NUMBER (recommended)
For FedEx & UPS return, insert official receipt that billed to your account
or credit card. Don’t put Embassy as the sender.
FOR OFFICIAL USE ONLY:
DATE PROCCESSED __________________
VISA NUMBER ______________________
TYPE OF VISA ______________________
ROYAL EMBASSY OF CAMBODIA
TO THE UNITED STATES OF AMERICA
4530 16
th
Street N.W.
Washington D.C. 20011
202-7267742 www.embassyofcambodia.org
9:00-12:00pm / 1:00-4:00pm Monday to Friday
,
TOURIST VISA REQUIREMENTS
- Completely filled-up VISA Application Form (one copy)
- One (1) piece of 2x2 Passport picture (recent six (6) months)
- Visa Fee (Bank/Cashier Cheque or Money Order) in USD
- Payable to Embassy of Cambodia
- Actual Passport (REQUIRED)
- Valid at least six (6) months upon entering Cambodia
- At least two (2) available Passport pages for Visa sticker
and date stamps
KINGDOM OF CAMBODIA
Nation – Religion - King
2 x 2
One (1) Passport picture
Recent at least
six (6) months
Securely Attached
Paste or Stapled
L/R (side-to-side)
(*) required information
I hereby declare that all information on this form are true and correct.
________________________
*Signature
_______________________________________________
*Applicant Full Name in print & Date Signed
201903
