Immigration Act, 2002 (Act No. 13 of 2002)RegulationsImmigration Regulations, 2014AnnexuresAnnexure A: FormsForm 21 (DHA-1684) |
(DHA-1684) Form 21
ORDER TO ILLEGAL FOREIGNER TO DEPART FROM REPUBLIC
[Section 7(1)(g); Regulation 30(4)]
To: ...........................................................................................................................................................(name(s) and surname)
Date of birth ..................................................................................Passport No ..............................................................................................
Expiry date..................................................................................... Place of issue...........................................................................................
Residential address: .......................................................................................................................................................................................
Nationality: ................................................................................Country of origin: ........................................................................................
You are hereby notified that as an illegal foreigner in contravention of the Act, you are guilty of an offence for which you may be charged in a court of law.
However, as you have undertaken to leave the Republic voluntarily, you are hereby ordered to leave the Republic by ................................................................................ (time) on ............................../.............................. /20.............. failure of which you shall be arrested and detained pending your deportation.
Declaration by immigration officer
...........................................................................................................................................(name(s) and surname) hereby declare that I am satisfied that the holder hereof has complied with the provisions of regulation 30(4).
...................................................................... .............................................................. .........................................................
Signature of immigration officer Place Date
IMMIGRATION OFFICER'S PARTICULARS
Name and Surname:
.....................................................................................................................................................................................................................................
Appointment number:
.....................................................................................................................................................................................................................................
Rank/position ...............................................................................................................................................................................................................
Office: ...................................................................................... Province: ....................................................................................................................
SUPERVISOR'S PARTICULARS
Name and Surname: ......................................................................................................................................................................................................
Rank/position ................................................................................................................................................................................................................
Contact No.: Tel: ............................................................................................................................................................................................................
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge receipt of the original of this notice.
...................................................................... ...................................................................... ......................................................................
Signature of illegal foreigner Place Date
Witness:
Name and surname ...................................................................... Signature: ......................................................................
CERTIFICATE BY INTERPRETER
I, ............................................................................................................................................ (name(s) and surname) of ............................................................................................................................................ (*business/residential address) with telephone number .................................................................. and cell number ...................................................................................... hereby confirm that I have mastered ................................................................................... (state language) and that I have explained to ..................................................................................................................................(name(s) and surname of foreigner) the contents of this notice in the said language and that I am satisfied that the said foreigner fully understands it.
...................................................................... ...................................................................... ......................................................................
Signature of interpreter Place Date
*Delete which is not applicable