MASA Visa Form (2

MASA Israel Visas
For participants travelling on a MASA program starting in January or February 2011.
AZYC SHNAT PARTICIPANTS SHOULD COMPLETE A DIFFERENT FORM VIA THE AZYC
One year Israel visas are available to participants on all MASA approved Israel Programs. The applicable
visa is an A2 visa – a multiple-entry student visa. This application form is for participants traveling on a
MASA approved program, departing Australia in early 2011.
Eligibility
To apply for a 1-year visa, you must:
1. NOT be Israeli (see below for criteria),
2. be an approved participant on your MASA Israel Program,
3. have completed an online MASA application,
4. Hold a passport that is valid for at least 6 months after the ticketed date of your return to Australia
after your Israel Program.
You are considered Israeli if you meet one or more of the following criteria:
1) You were born in Israel,
2) One or both of your parents were born in Israel, or at some stage in their lives made Aliyah,
3) You have an Israeli passport,
4) You have previously made Aliyah.
Israeli Citizens
If you are Israeli, you must contact the Israeli Embassy in Canberra directly to arrange your citizenship,
Israeli passport and military status. If you are unsure, please contact the Embassy and clarify your status.
Israelis that fail to travel to Israel on an Israeli passport may be prosecuted according to Israeli law.
How to Apply?
Complete this application form in full and wait to be contacted with more information in early
November. You will be given instructions for drop-off points in late November. Late application forms
will not be accepted. Your passport and visa will be returned to you by the end of December.
If, for whatever reason, you are unable to meet the deadlines of this process – please contact the Israeli
Embassy in Canberra directly.
CONTACT PEOPLE
AUJS AVIV
ISRAEL BY CHOICE
Sydney
Mark Fischer
ed@aujs.com.au
02 9662 4855
Melbourne
Helen Lewitan
hlewitan@hotmail.com
0412 469 626
Melbourne & Other Cities
Liron Murphy
liron137@gmail.com
0430 097 937
Sydney & Other cities
Keren Port
kerenport@hotmail.com
0405 342 434
OTHER PROGRAMS
All Cities
ZFA Israel Programs
Brendan Bensky
OR
Shani Gershon
israelprograms@zfa.com.au
03 9272 5584
MASA Israel Visa Application Form
Complete the following details and checklist. You will be contacted in November with submission
instructions.
Participant Name: ______________________________________________ Program: _______________________________
Date of Birth: ____ dd / ____ mm / ______ yyyy
City: ____________________________
Submission Checklist
o A completed three-page visa application form (on the next 3 pages)
o 2 passport photos attached with the participant’s name on the back of each.
(Please attach with paperclips, do not sticky tape or staple!)
o Your current passport
o Participants under 18 must also submit the following Parent Release Form below.
Parent Release (for under-18 participants ONLY) – TO BE NOTARISED
I, ____________________________, the father of ____________________________ (participant name) and
I, ____________________________, the mother of ____________________________ (participant name) authorise the Israeli
Embassy to issue a MASA one year Israel visa for ____________________________ (participant name), to be issued
immediately.
Mother Name: ___________________________________
Mother Passport Number: ___________________________________
Mother Signature: ___________________________________
Father Name:
___________________________________
Father Passport Number: ___________________________________
Father Signature: ___________________________________
Participant Name: ___________________________________
Participant Passport Number:
Witness Full Name:
___________________________________
___________________________________
Witness Signature: ___________________________________
Witness Stamp:
Date: _ _ / _ _ / _ _ _ _
‫מדינת ישראל‬
‫משרד הפנים‬
State of Israel
Ministry of Interior
‫בקשה למתן אשרת כניסה לישראל‬- 1/‫טופס ק‬
Application for entry visa to Israel
Instructions for completing
application form:
1. Please attach a recent photograph.
2. If application is not for the purpose of visit, specify
reasons and supply documentation.
3. Please fill in following details in Hebrew or
English.
:‫הוראות למילוי הטופס‬
.‫ נא לצרף תמונה שצולמה לאחרונה‬.1
‫ אם מדובר בכניסה לישראל שאינה למטרת ביקור‬.2
.‫נא לצרף מכתב הסבר ומסמכים‬
‫ נא למלא את הפרטים הבאים בעברית או‬.3
.‫באנגלית‬
‫שמות קודמים‬
Previous family name
‫שם האם‬
Mother’s name
‫שם האב‬
Father’s name
‫שם פרטי‬
Given name
‫שם משפחה‬
Family name
‫אזרחות קודמת‬
Previous nationality
‫אזרחות נוכחית‬
Present
nationality
‫משלח יד‬
Occupation
‫תאריך לידה‬
Date of birth
‫מקום לידה‬
Place of birth
‫מצב משפחתי‬
Family status
‫ניתן ע"י‬
‫בעברית‬
‫אה‬/‫□ נשוי‬
‫ה‬/‫□ רווק‬
Issued at
‫נה‬/‫□ אלמן‬
‫ה‬/‫□ גרוש‬
In
□ married
□ single
English
□ widowed □ divorced
‫ אנא ציין אם‬,‫אם ברשותך תעודת מעבר שהוצאה ע"י מדינת ישיבתך הקבועה‬
‫מטרת הכניסה לישראל‬
.‫הוענקה לך אשרת חוזר ומה תוקפה‬
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 its validity.
□ Passport
□ Laissez passer
‫בתוקף עד‬
‫ניתן בתאריך‬
valid until
Issued on
1
‫□ דרכון‬
‫□ תעודת מעבר‬
‫מספר‬
number
‫מספר הטלפון‬
telephone no.
‫ארצות מעבר‬
Countries of
transit
permanent address abroad
‫הרחוב ומספר הבית‬
Street and house no.
‫זמן השהות‬
‫המשוער‬
Approximate
duration of stay
‫המען הקבוע בחו"ל‬
‫הארץ‬
Country
‫העיר‬
City
‫תאריך ומקום הכניסה‬
‫המשוער לישראל‬
Anticipated date and
place of entry to
Israel
‫הכתובת בישראל‬
Address in Israel
(‫עבודה‬/‫עולה‬/‫תושב‬/‫ארעי‬/‫לפי איזה סוג רישיון ישיבה )ביקור‬
Category of residence permit (visitor, temporary resident,
resident, immigrant, work)
‫תאריכי שהיות קודמות בישראל‬
Dates of previous stays in Israel
particulars of dependants included in the application
‫תאריך הלידה‬
Date of birth
‫מקום לידה‬
place of birth
spouse
‫בת הזוג‬/‫בן‬
‫שם האב‬
father’s name
‫שם נעורים‬
maiden name
Children under the age of
18
‫תאריך הלידה‬
Date of birth
‫פרטים של הנכללים בבקשה‬
‫שם פרטי‬
given name
‫שם המשפחה‬
family name
18 ‫ילדים עד גיל‬
‫מקום הלידה‬
Place of birth
‫שם פרטי‬
Given name
.1
.2
.3
Relation/references in
Israel
‫כתובת‬
address
‫מכרים בישראל‬/‫קרובים‬
‫יחס הקרבה‬
relationship
‫שם‬
Name
.1
2
.2
declaration
‫הצהרה‬
‫ אני מצהיר בזה‬,‫ כמו כן‬.‫אני מצהיר שהפרטים שנמסרו לעיל נכונים ונמסרו בהכרה שהם מהווים יסוד לדיון בבקשתי‬
‫ לא חליתי במחלה העלולה לסכן את‬.‫ לא פעלתי נגד העם היהודי ובטחון מדינת ישראל‬.‫שלא עברתי עבירה פלילית‬
.‫ לא קיים נגדי צו מעצר שיפוטי ואינני מבוקש על ידי המשטרה של מדינה כלשהי‬.‫בריאות הציבור‬
,‫ ידוע לי שבמידה ויש כנגדי מניעה כאמור‬,‫ה בזאת שלא קיים כנגדי צו הרחקה ולא סירוב כניסה לארץ‬/‫אני מצהיר‬
.‫תמנע ממני אפשרות להיכנס לישראל ואוחזר למדינה ממנה הגעתי‬
‫ באם‬,‫ לסרב כניסתי לתחומי מדינת ישראל‬,‫ידוע לי כי אין בקבלת האשרה משום ביטול סמכות משרד הפנים בישראל‬
.‫יס תבר שהאשרה התקבלה על סמך פרטים כוזבים‬
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 against me and I am not wanted by
the police of any country.
I hereby 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.
I am 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.
Applicant’s
signature
3
‫חתימת‬
‫המבקש‬
date
‫תאריך‬
place
‫המקום‬