By completing and submitting this form you are indicating that you want your details registered for the purposes of repatriation from Fiji back to Vanuatu.

Part A - Personal Details (Only one (1) person to complete the form, if you have dependents add them in Part C)

First Name 

Last Name 

Age 

Gender

Male Female

Telephone No.

Email Address

Part B - Occupation/Nationality/Medical Details

Nationality

Passport No. 

Resident Permit No. (If not citizen)

Status

Student Working/Residing in Fiji

Location 

Medical Conditions

Asthma Diabetes Heart Condition High Blood Pressure

Part C - Dependents

	Full Name	Age	Citizen/Resident	Passport No.
1			Citizen Resident
2			Citizen Resident
3			Citizen Resident
4			Citizen Resident
5			Citizen Resident
6			Citizen Resident
7			Citizen Resident
8			Citizen Resident

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