Mu (Form) NA5

Ban hnh km theo thng t s 04 /2015/TT-BCA

ngy 05 thng 01 nm 2015

T KHAI NGH CP TH THC, GIA HN TM TR (1)

APPLICATION FORM FOR VISA ISSUANCE, STAY EXTENSION
Dng cho ngi nc ngoi ang tm tr Vit Nam
For temporary residence foreigners in Viet Nam

I- Ngi ngh The applicant:

1- H tn (ch in hoa):.................................................................................................................
Full name (in capital letters)

2- Gii tnh: Nam

Sex

Male

N
Female

3- Sinh ngy.......thng.......nm..........
Date of birth (Day, Month, Year)

4- Quc tch gc: ..........................5- Quc tch hin nay:.........................

Nationality at birth

Current nationality
6- Ngh nghip/chc v: ..............................................................................
Occupation/position
7- H chiu/giy t c gi tr i li quc t s: .........................loi (2): .....................
Passport or International Travel Document number
Type
C quan cp: ................................... c gi tr n ngy:........./............./.....................
Issuing authority:
Expiry date (Day, Month, Year)
8- Nhp cnh Vit Nam ngy:......./....../........
qua ca khu: ........................
Date of the latest entry into Viet Nam (Day, Month, Year) via entry port
Mc ch nhp cnh: ..............................................................................................................
Purpose of entry
9- c php tm tr n ngy: ......../........../................
Permitted to remain until (Day, Month, Year)
- a ch tm tr ti Vit Nam: ............................................................................................
Temporary residential address in Viet Nam
- in thoi lin h/Email ....................................................................................................
Contact telephone number/Email

II- C quan/t chc hoc thn nhn Vit Nam mi, bo lnh:
Hosting organisation/ family relative in Viet Nam
1- Tn c quan, t chc Name of hosting organisation:
.......
a ch Address .........................................................................................................................
in thoi lin h/Email Contact telephone number/Email .................................................
2- Thn nhn bo lnh (H tn): ..............................................................................................
Hosting family relative (full name)
Sinh ngy.......thng.......nm..............
Date of birth (Day, Month, Year)
Giy chng minh nhn dn/h chiu/th thng tr/th tm tr s: .........................
Identity Card/Passport/Permanent/ Temporary Resident Card Number
Cp ngy: ....................c quan cp: .....................................................................................
Issuing date
Issuing authority
Quan h vi ngi ngh: ............................................... (3)
Relationship to the applicant
a ch thng tr/tm tr ti Vit Nam: ........................................................................
Permanent/temporary residential address in Viet Nam
in thoi lin h/Email: .....................................................................................................
Contact telephone number/Email

III- Ni dung ngh Requests:

1- Cp th thc: mt ln
nhiu ln

c gi tr n ngy: ......../........./...........
Multiple
Valid to (Day, Month, Year)
2- Gia hn tm tr n ngy: ........../............/.............
To extend the duration of stay until (Day, Month, Year)
3- L do Reason(s).........................................................................................................................
IV- Nhng iu cn trnh by thm Additional
statements: ........................................... ............................................................................................
...............................................................
To issue a visa

Single

Lm ti ... ngy.......thng........ nm..........

Done at ............. date (Day, Month, Year)

Xc nhn (4) Certified by

(k, ghi r h tn, chc v, ng du)
Signature, full name, title and stamp

Ngi bo lnh
(k, ghi r h tn)

Ngi ngh
(k, ghi r h tn)

The sponsors signature and full The applicants signature and

name
full name

Ghi ch Notes:
Gi hng dn ghi ti liu: 0946639599
(1) Mi ngi khai 1 bn, km h chiu hoc giy t c gi tr i li quc t v 01 nh mi chp c 4x6cm, phng nn trng, mt
nhn thng, u trn, khng eo knh mu, np trc tip ti c quan qun l xut nhp cnh.
Submit in person one completed application form enclosed with passport or International Travel Document and one recently
taken photo in 4x6cm size, with white background, front view, bare head without sunglasses at the Immigration Office.
(2) Ghi r loi h chiu ph thng, cng v, ngoi giao hoc giy t c gi tr i li quc t.
Specify type of passport whether it is Ordinary, Official or Diplomatic; or specify name of the International Travel Document.
(3) Km theo giy t chng minh quan h.
Enclose supporting documents to prove the family relationship
(4) Trng hp do c quan, t chc mi, bo lnh, hoc ngi nc ngoi c th tm tr mi, bo lnh th th trng c quan, t
chc xc nhn.
Be certified by the head of the organization if the sponsor is an organisation or a foreigner with Temporary Resident Card.
Trng hp cng dn Vit Nam, ngi nc ngoi c th thng tr mi, bo lnh, th Trng Cng an phng, x xc nhn
cc ni dung ti im 2 Mc II.

Be certified by the Chief of the local Ward/Commune Public Security where the sponsor is residing permanently if the
sponsor is a Vietnamese citizen or a foreigner with Permanent Resident Card.