State of Israel Sew? nyt Ministry of Interior naan Twn ORIW) ATIAY DV NWR inn? Apr Application for Working Holiday visa to Israel Instructions for completing application form: cosran 77 MTA Please attach a recent 5x5 photograph as well as a photo. TIN D'S MMNAMN? NPIS SXB ANN qIW? of the first page of the passport {VOT 7 NOR Pease fill in following details in Hebrew or WAI] WWI DOTA’ NI? Ww English. 78 ‘Attach a updated document of integrity mma wr nToN 787 x Attach the fight ticket to and from Israel aim 7a 70% OTD TS? Attach medical insurance for the whole duration of stay bit HRCI ee nda Harn ‘ARN DIPEIN TAD PAP TTS? ‘Attach the payment receipt for the Dany mT Ten ow RVG oo mn oo Previous family name_| Mother's name | Father's name | Given name Family name ote MINA aeRO MINT Tivos aT PRR ar BP Previous nationality _| Present nationality | Occupation Date of birth _ Place of birth Passport wT o nso as i Laissez passer tawn mwa 8 Family status Dama | wa | as 1800 moO Aveo) AS valid unt Issued on Issued at number | mime O avwra Go OD married single | In English _ __|© widowed 0 divorced _| PS RR DPA TPE AND Mb ASTD TaN NTT NGA Ow TO AOA TOD ans In TOT wn Nw 7? PABA OR Purpose of entry into Israel If you hold a Laissez-Passer issued by the State of your permanent residence, state whether you have a return visa and indicate is validity. permanent address abroad prima apn wo Tere we Wai som TMA TA Pint telephone no. Street and house no. City Count ee swiwnn Sewn? wiwnA nwa nan Countries of | Approximate | Anticipated date and transit__| duration ofstay_{_ place of entry to Israel ‘Address in Israel 3m 1 ToyState of Israel OR npn Ministry of Interior min Twn SRW) TAY SPO NWR jn? Nwp2 Application for Working Holiday visa to Israel TRATION TRAPS ATR TTT TO TTT RTI TTT aA Category of residence permit (visitor, temporary resident, resident, Dates of previous stays in Israel immigrant, work) declaration 717371 (313 NPI VT? NO OTM oAG TSN Non Wio PH? NUNIG DOING TAR Ie 8? 2D APTN NON TTD wwA TaD NYS NP. TTIW NW NW AI TagD YER 27 7D WPAN -INR VIN W TSN WTA) OP XP WPA MNT Ne 1907 API7vn APM Msn “nw73 ATM 2H Mee 7799 OAT DAG *7 DIT? PIR? 109 ATO NIT APIA 1 7793 OP RO TTI T/TANN IR snvan mann APTN? MRI Aw? VIDA? NAwWEX “INN DIN MEI TI TTA INN oD IW? ARI DIT TN MIND 71072 Dien TWRA NIPA Pe 72 +7 DIT aNd Wis Wo 7 AAPA MwNAW TaN? BRA ,7R1w { 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 against me and I am not wanted by the police of any country. Thereby declare that I have not been issued with a restraining order. Furthermore, I have not been denied entry into Israel. I am aware that if a preventive order of this kind has been issued against me, I will be denied entry into Israel, and will be sent back to my country of origin. Tam also aware that the receipt of a visa does not in any way invalidate the right of the Israel Ministry of the Interior to deny my entry into the territory of the State of Israel, if it becomes clear that the visa was issued on the basis of false information, a) Applicant's monn date ren place ann signature yan 3.7m 2 Toy