ntnл

Photograph

lnstructions for completing application form: :aY±k L±TLnT n±xL±

1. Please attach a recent photograph. . ntчnnh nht ntnл çч h nn .1
2. If application is not for the purpose of visit, specify чt tz лчunh ntn hnч th tn>z чzt n dn .2
reasons and supply documentation. .dt>n nt чz zл>n çч h nn
3. Please fill in following details in Hebrew or English. .лth nnz tn лtчznz dtnz dtuчv лn nhnh nn .3
tл чv n
zhz ч n tnt h
For official use only ID/Driver Licence No.:_______________

dLn ± n±n dx d Lx d LkLY d ny n d

Previous family name Mother's name Father's name Given name Family name
nLLLKL
Denny Rafael Salcedo ln English

L nT n n±nl x LT yLLxn LT 7L x n
Occupation Nationality Date of birth Country of birth Religion
nLLLKL
Welder Venezuelan 22-Sep-1981 Venezuela N/A ln English

LLKn n ±Kn y±3L Lnny n L n

Laisser passer Passport Family status
n ç tлz ytчnлz yлtn чv n ttч
tt n nLLLKL
ynhn tч
Valid untill Issued at Number ✔ Married Single
ln English
03-Oct-2032 Venezuela 171788026 Widowed Divorced

Purpose of entry into lsrael : : Tx L LT a L -3 n L kn

Particulars of dependants included in the application LL dLTT3- T dLkLY

Spouse a± nL/yL

LT yLLxn LT 7L x Lx d d LL ± K - d LkLY d ny n d
Date of birth Country of birth Father's name Maiden name Given name Family name
nLLLKL
ln English

Children under the age of 18 18 TLa K dL TL

LT yLLxn LT 7L x LkLY d
Date of birth Country of birth Given name
ln English nLLLKL ln English nLLLKL ln English nLLLKL
1
2
3
e

* The form continues on the back of the page ç h чznn y n 33 / TK

.чtчtzh > hh yлtnvz чt tn ynn nz t чt tn hn чtn . ч n dth лht z л h nл>n n n n чt tn : чn
Denn
.dtлtчt лч n htz tthn z t nh dn ç tл h> чt tnh ytn
Note: This certification may be used as a proof for the submission of the application and for paymant of fees. Keep this certificate and produce it whenever dealing
with matters concerning this application. This certificate is not valid unless it carries a service fee stamp.
 y± Y Tk LY an T»±nl K ± L yKn
Telephone No Permanent address abroad
лtz чv nt ztnч чtn yчn
nLLLKL
Street and house No Town Country
÷584244945134 ln English
Building 45, apt pb-d Punto Fijo Venezuela

:L TxL L n±aL -T LLLK T x- L L± Lx TK K ± nx

On notification of permit, please inform lsraeli Representative Office in:

Declaration L

nh .лththv чtzn tлчzn nh z чt n tnn ,y> tn> .tл zz ytt h t t dttt n d ч> z tч nnt dtnt>n htnh tч nn dtuчv чt n tnn
t»n tzn tnntnt tutvt ч nn t t n dtt nh .чtzt лtntчz лn y> h hthn hnnz tлthn nh .hnч t лnt n ytnuzt t t t dn n tлhnv
.t h> nt n h чu n

I declare that the particulars contained in this application are correct and have been made in awareness of the fact that they are to serve
as basis for the consideration of my application. I also declare that I have not committed any criminal offence or any act directed against
the Jewish people or the security of the State of Israel and that I am not affected with any illness which might endanger public health. There
is no judicial warrant of arrest against me and I am not wanted by the police of any country.

члttn лn tnnh nn .2
(dt)tnчnn (t)tnn . чtnn vt лh yчnh tл tn> чnnh h»n лn t n h (dt)zttnлn (t)tnn t dtnt>n d (tn)tлч n dtuчv (dt)ч nn (t)tnn
(чt nn)чt nn y> hn n t .члtt d tn ntn tvh ,tn tnz t t vл чn z tn ytt ч ntn dtл tnvh hnч t лn (t)zt nt tthn dttthtn t yn tn
. hn> лtn t ntt л dn h»tnh h»n лч n h ч z h t л n t h> h nnh h h (dt)zttnлn (t)tnn .dtnv ч n ,d чnt thnh > hh
.ytn nzunz t h> dth л tn ч> hz t nh / hz t yn tn z (dt)чt n (t)tnn
2. * Delete whichever is inapplicable
I (we) certify that the particulars contained in this application are correct and I (we) undertake to employ the a/m, after his arrival to Israel,
for the period stated. I (we) am (are) responsible that the said person and the persons accompanying him will leave Israel before the expiry
of his (their) permit of residence or upon the termination of his employment by me (us) whichever is the earlier event. I shall notify the district
office of the Population Administration, Ministry of the Interior, of his departure. I undertake to reimburse the Government for any expense
which may be incurred in connection with the deportation of the said person or persons. I declare that the person for whom the visa is
requested *will / will not receive a renumeration of other payment in foreign currency.

28- Nov-2022 Venezuela

Signature of applicant: Denny Salcedo (Nov 28, 2022 10:38 AST): zn лntлn Date: :ytчnл Place: :dt n

n> htz

Fincal stamp
tn tn hnvn лnлtnt ytn n лntлn
Signature and official stamp of establishment or institution

For official use only L n ±nL T

:dttz :dt nz hz лn z
:hz n t v лntлn :hz n t v d
чntn z»t ч лtчn ytn »nчz zn
лnzu h dt n zчt z ч tn z
ytt ч лnлtn : t v лntлn : t v d :ytчnл

znh nh n ztчt hn n t
tлh çчt n tnnn лn zл>nz

33 / TK