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Umrah
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Tick appropriate Package
Basic Standard
Standard Plus
Executive
VIP
You are
Are you a new customer
Returning customer
HOW DID YOU HEAR ABOUT US
ADVERT
Newspaper
TV
Radio
Handbill
Sticker
Agent
ELECTRONIC
Google
Website
SMS
SOCIAL MEDIA NETWORK
Facebook
Instagram
Whatsapp
LinkedIn
ALL ABOUT YOU
Full name as it appear on your Int’l passport:
Date of Birth:
Place of Birth
Nationality:
Sex:
Male
Female
Marital Status:
Single Married
Divorced
Widowed
Separated
Religion:
Religion Sect
What language(s) do you speak fluently
What is your qualification
What is profession
Are you Self Employed:
Yes
No
If yes, clearly state what you do
YOUR PASSPORT INFORMATION Do you have valid international passport:
Yes
No
Passport Number
Issue & Expire Date
Is this your first passport:
Yes
No
Previous Passport No:
Previous Passport Issue & Expiry date
Home Address
Business Address
Mobile Numbers
Email Address
*
Name of spouse:
Is your spouse travelling with you?
Yes
No
Contact address:
Home:
Work:
Email:
Mobile:
Do not you have children?
Yes
No
Is any traveling with you?
Yes
No
Name of child/children traveling with you;
Sex
Male
Female
Both
Age:
Contact no:
Will you be traveling with other people?
Yes
No
If yes, please state Name, relationship and contact no
Have you performed Umrah before?
Yes
No
Have you performed Hajj before?
Yes
No
Have you had any cause to stay in Saudi Kingdom from UMRAH period to HAJJ period?
Yes
No
Have you applied for Saudi Visa Before
Yes
No
Have you been refused a Saudi visa before
Yes
No
Have you been ever refused entry to Saudi or had to leave to encounter or remain cancelled?
Yes
No
Have you been refused Visa to another country
Yes
No
SECTION 5: MEDICAL HISTORY
Tuberculosis
Yes
No
Migraine Headache
Yes
No
Diabetes
Yes
No
Heart Attack
Yes
No
High & Low Blood Pressure
Yes
No
Whooping Cough
Yes
No
Asthma Cough
Yes
No
HIV
Yes
No
Hemorriod/Pile
Yes
No
General body ache after little stress
Yes
No
Rheumatism
Yes
No
If you have answered YES to question 5.1 - 5.11, please answer question 5.12 - 5.15 otherwise go to question 5.16
How often do you have this illness ?
When was your last treatment ?
When was the first time you noticed this illness ?
Is your illness hereditary?
Yes
No
Have you had any serious illness in the past that has been cured?
Yes
No
If you have answered YES to question 5.17 - 5.19
What is the nature of the illness
How long did you suffer from this illness
What were the medication/drug adminstered to you
Do you require any special attention or assistance during your stay in saudi due to old age?
Yes
No
Do you require a wheel chair or stretcher perform you rite
Yes
No
Do you have any form of deformation/Disability
Yes
No
If Yes please tick any form deformation
Blind
Deaf
Dumb
Handicap
YOUR FINANCE How much money available for your stay in Saudi Arabia
Who is paying for the pilgrimage?
Sponsor’s Contact and phone number
ADDITIONAL INFORMMATION
DECLARATION:
To be complete by all pilgrims personally. I hereby certify that the above statement are true to the best of my stay in Saudi Arabia. I shall abide with all laws and regulations in the Kingdom , I am aware that Alcohol, Drugs Narcotics and indecents publications violating public morality and all types of religions or political pamphlet are prohibited from entering the kingdom of Saudi Arabia, whether for personal use or otherwise. I accept that if i violate the laws and regulation of the Kingdom of Saudi Arabia, i shall be subjected to penalty. I am aware that the airline tickets once issued before notification of cancellation cannot be refunded.
Date
Full Name
*
First
Middle
Last
Signature
IN THE PRESENCE OF NEXT OF KIN
Submit