1. Personal and Travel Information
2. Confirm your details
3. Payment method

2. Confirm your details

Applicant Information

  • Last Name(s) / Surname(s):
  • First Name(s) / Given Name(s):
  • Birth Date:
    --
  • Country of Birth:
  • Place of Birth:
  • Gender:
  • Country of Citizenship / Nationality:

Passport Information

  • Country Passport:
  • Passport number:
  • Passport Date of Issue:
    --
  • Expiration date:
    --

Other Data

  • E-mail Address:
  • Telephone Number:
  • Intended Date of Entry:
    --
  • Port of Entry:
  • Address During Visit (Address in Cambodia):
  • Address Line:
  • Street number:
  • Apartment Number:
  • Address Line:
  • Country:

Background Questions

  • Have you ever been refused a visa or permit, denied entry to, or ordered to leave Cambodia?:
    No
  • In the past two years, were you diagnosed with tuberculosis or have you been in close contact with a person with tuberculosis?:
    No
  • Do you have one of these health conditions?:
    No
  • Have you ever committed, been arrested for, been charged with or convicted of any criminal offence in any country/territory?:
    No
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