Mbiemri/Suriname_________________________________________________________

Emri/Name ___________________________________________________________________

Datëlindja/Date of birth ___/___/________

Gjinia/Gender M – F

Vendlindja/Place of birth _______________________________________________________

Shtetësia /Nationality ______________________

Lloji i dokumentit/Type of document _____________________________________________

________________ N. __________________________________

Autoriteti lëshues/Issued by _____________________________________________________

E vlefshme nga /Valid from ___/___/_______

Deri në /to ___/___/_______

Adresa në Republikën e Shqipërisë /Address in Albania, Rruga, Lagjja /Avenue,

Square____________________________________________ Nr. _________

Qyteti/City ___________________________________________________________________

Qarku/Province____________________________________________________________

Data e hyrjes / Entry date_______________________________

Koha e qëndrimit/Duration of stay: ditë/days ____

Motivi i hyrjes/Reason of entry: _______________________________________________

Data/Date/ ___/___/_______ Firma/Signature____________________________

Vula