| 1. Mr./Mrs./Miss |
| (First Name) (Middle Name) (Surname) |
| 2. Date of birth |
| (Day) (Month) (Year) |
| 3. Country of Birth |
| 4. Nationality |
| 5. Usual Place of Residence |
| 6. Occupation |
| 7. Home Address |
| Street Zip Code |
| |
| Country State |
| 8. For all Departing Passengers: Port of Disembarkation |
| 9. For all Arriving ) (a) Port of Embarkation |
| Passengers ) (b) Intended Address (Full Address) |
| |
| 10. For non-Residents ) (a) Type of Accommodation |
| Arrivals Only ) |
| □ | □ | □ | □ |
| Hotel/ Guest House | Rented Apt./ Cottage | Relative's/ Friend's House | Other |
| (b) No. of Accompanying Family Members |
| (c) Purpose of Visit |
| (d) Intended Length of Stay |
| (e) For Vacationers Only: |
| (i) Are you on a Prepaid Package |
| □ Yes □ No |
| (ii) If Yes, Name Package Provider |
| (f) Visit to Saint Lucia ... 1st ... 2nd ... 3rd ... Other ... |
| Identification |
| | |
| Date | Signature of Passenger |
| | | |
| Signature of Immigration Officer | Date | Stamp |
| FOR OFFICIAL USE ONLY |