4 DOLIVI .4 2425 low 24 04/26 1:00M1 Ø•• 101 5 24 08/24 2:10151 90HVG 42121 M 21 00/26 3: 22PM 9042vm M21 M 24 04/26 3:54114 BOLIVIA pm21 D? 29 TIO 0•/27 20:111 404.223 4. 4721 n 10 09/27 1.0:15114 •NOCIVZ • • 001 Of 51 00/21 13:111% 00121 . 4 IMM. OT 32 04/27

tolen? Have you ever visited other countries in the past ten years? yes Country name COSTA RICA Visit date 12 February 2013 'Ma Country name BOLIVIA Visit date 15 February H. 013 tai Have you ever visited other countries in the past ten years? If the answer is yes you mu t list all countries

arge Purge I. Tot 00/111 12:1011 POUT/ •• 2 X:01 DT 4.52 4.52 2 NED 011/1/ 8:552/1 SOUP •• 1 2501 Dr 2.26 3.24 3 04/19 1010014 BOLIVIA 1 MGR DT 2.19 3.11 4 04/11/ 10:09AN BOLIVIA 1 9.101 DT 2.19 2.19 3 02/L9 1:32911 BOLIM •• 1 21421 DT 2.26 2.26 6 08/19 1:41