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Family Name / Surename (Nom de famille/Prénom)
First Name(s) (Prénoms)
Sex
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Male
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Date of Birth / (Date de naissance)
Country of Birth (Lieu de naissance)
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Dominica
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
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Aruba
Australia
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Chile
China
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Cook Islands
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Korea, Republic Of
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Liechtenstein
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Nigeria
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South Georgia , S Sandwich Is.
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Sint Maarten
St Martin
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Occupation
Town/City of Residence
Country of Residence
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Dominica
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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Bangladesh
Barbados
Belarus
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Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
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Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia (Local Name: Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Islands
Holy See (Vatican City State)
Honduras
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Hungary
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India
Indonesia
Iran (Islamic Republic Of)
Iraq
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Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
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Korea, Dem People'S Republic
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Dem Republic
Latvia
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Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
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Moldova, Republic Of
Monaco
Mongolia
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Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Ant Illes
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint K Itts And Nevis
Saint Lucia
Saint Vincent, The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia , S Sandwich Is.
Spain
Sri Lanka
St. Helena
St. Pierre And Miquelon
Sudan
Suriname
Svalbard, Jan Mayen Islands
Sw Aziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
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United States Minor Is.
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis And Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Sint Maarten
St Martin
Passport No. (Numéro de passeport)
Place of Issue (Lieu de déliverance)
--Select--
Dominica
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia (Local Name: Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard And Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic Of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Dem People'S Republic
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Dem Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Ant Illes
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint K Itts And Nevis
Saint Lucia
Saint Vincent, The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia , S Sandwich Is.
Spain
Sri Lanka
St. Helena
St. Pierre And Miquelon
Sudan
Suriname
Svalbard, Jan Mayen Islands
Sw Aziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Is.
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis And Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Sint Maarten
St Martin
Email Address ( Adresse mail)
Contact Number (Numéro de contact)
Contact Address in Dominica (in full) (Adresse de contact en Dominique)
Length of Stay in Dominica(Durée du séjour à la Dominique)(jours)
Purpose of visit (Objet de la visite)
Vacation
Meeting
Business
Convention
Wedding/Honeymoon
Sports
Study
Other
Accommodation Type (Type d'hébregement)
Hotel
Guest House
Private Home
Port of Last Depature (Port de dernier départ)
How are you travelling to Dominica? (Méthode de voyage)
--Select--
Air
Sea
Arrival Flight/Ship Name (Vol d'arrivée / Nom du navire)
Arrival Date
Arrival Time
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