SCHEDULE
FORM 1
GOVERNMENT OF WESTERN SAMOADECLARATION TO BE MADE
BY PERSONS ARRIVING IN WESTERN SAMOA
(Immigration act 1966)
A. For persons ordinarily resident in Western Samoa
Name of Ship: ..............….................... Date of Arrival: ...……....................…...............
1. What is your:
(a) Surname: ...............…..................... (b) Christian names:
…….............…..................
2. What is:
(a) Your Sex: ..................…................. (b) Your Age:
.......……............…......................
3. What is your address in Western Samoa: .................……..........….........................
.............................................................…
….............................................................
4. Are you a citizen of Western Samoa:
.................................................................
5. Have you the status of permanent resident of
.................................................................
Western Samoa?
6. How long have you been absent from Western
...................................................…………
Samoa?
7. Are you bringing with you any firearms, ammunition
.....................................................
or explosives?
If so state particulars
..............................................................…
8. State particulars of children under 14 years of age
arrive with parents or guardian:
(NOTE - To be filled in only on declaration made by father if both
parents arrive by the
same ship).
Name: ...............................……………….......... Age:
..............................………..
............................................................................
Signature of Applicant
I do solemnly declare that the answers made by me to the foregoing
questions are true and correct in every respect.
Declared at: .................... this ....................... day of
................. 19 ..........……….... before me.
Customs Officer
or Immigration
B. For persons not ordinarily resident in Western Samoa
For persons not ordinarily resident in Western Samoa
Name of Ship:..........................…................. Date of
Arrival: .........................................
1. What is your:
(a) Surname: ............................................... (b)
Christian names: ..................................
2. What is:
(a) Your Sex: .............................................. (b) Your
Age: ...........................................
3. What is your Nationality:
...................................................................................
4. Have you ever been previously in Western Samoa:
If so, when?
.................................................................................................................……………….
5. Are you bringing with you any firearms, ammunition or
explosives:...............................……………….
If so state particulars: ................………………............................…....................................................
6. State particulars of children under 14 years of age arriving with
parents or guardian:
(NOTE - To be filled in only on declaration made by father if both
parents arrive by the same ship).
Name Age:
7. What will be your address while in Western Samoa?
....................................................………………
(NOTE - To be filled in only on declaration made by father if both
parents arrive by the same ship).
Name: ............................................ Age:
......................................................………
8. When do you intend to leave Western Samoa?
..............................................................……….
9. What is your usual place of residence outside of Western Samoa (give
full address)
10. Are you in possession of a permit to enter Western Samoa?
..........................................………..
If so, state date and place of issue:
..............................................................................…………..
............................................................................
Signature of Applicant
I do solemnly declare that the answers made by me to the foregoing
questions are true and correct in every respect.
Declared at: .............…........ this ...........……....... day
of ......………............ 19 ...................……...... before me.
Customs Officer or
Immigration
Officer
FORM II
FORMS
Section 11
GOVERNMENT OF WESTERN SAMOA
PERMIT TO ENTER WESTERN SAMOA
(Immigration Act 1966)
PERMISSION is hereby granted to:
...............................................................................................................................................................................
to enter Western Samoa and to remain for period not
exceeding ..............................................…………………
subject to the following conditions:
1. That security in the sum of
$................................... be deposited, or a security bond
for that sum be lodged; and/or an onward or return travel ticket to a
place to which the said ........................................... has
permission to enter, be deposited.
That on arrival in Western Samoa he will be employed by
............................................... and will report to an
Immigration Officer when he ceases to be so employed.
3. That he does not change the address given on the Declaration to be
made on entering Western Samoa without notifying an Immigration Officer.
.........................................................
Immigration Officer
ISSUED AT: ...................................
DATE: .............................................
Signature of Permit Holder: ...........................................
