Ministerul Afacerilor Interne al Republicii Moldova

Biroul migraie i azil

Foto

Nr. dosar.
data........../................/20.
Certific identitatea persoanei i corectitudinea
datelor nscrise n cerere
____________________________
(Semntura persoanei

3X4

CERERE
pentru prelungirea dreptului de edere provizorie pentru rentregirea familiei (pentru membrii de
familie ai strinilor cu drept de edere n Republica Moldova)
Nume (Family/ last name)_________________________________________________________________________________
Prenume (Given/first name (s))_____________________________________________________________________________
Numele prinilor: Tata (father`s name)____________________Mama (mother`s name)_________________________________
Cetenie (Citizenship)________________ data/luna/anul naterii (date of birth) _____/______/________ Sex (gender) _______
Locul naterii (Place of birth): ara (country)_______________________ Localitatea (Town/city) _________________________
Adresa n ara de origine (Address in origin country)_____________________________________________________________
Paaport (passport) seria (series) ______ nr. (no.)_________________Eliberat de (issued by)_____________________________
la data (on)_____/_____/_______ valabil pn la (date of expiry) _____/______/_______________________
Permis de edere (type of card) ______ seria (series) _________nr. (no.)_____________ la data (on)______/______/_________
valabil pn la (date of expiry) _____/____/_______ IDNP (Personal code) _______________ scopul (purpose)_____________
Data ultimei intrri n Republica Moldova (last entry in Republic of Moldova)_________________________________________
Punctul de trecere a frontierei (border check point)______________________________________________________________
Solicit s mi se prelungeasc dreptul de edere provizorie pentru rentregirea familiei la so/ soie ( I request the extension
of the temporary residence right for the purpose of family reunification to spouse) nume, prenume (last name, first name
(s))_____________________________, posesor al permisului de edere (holder of the temporary residence permit ) ___________

seria (series) _______ nr. (no.) ______________ eliberat de (Issued by) _____________ la data (on) _____/______/_______
Valabil pn la (date of expiry)_____/_____/_______ IDNP (Personal code) _________________________________
Motivul pentru care se solicit prelungirea dreptul de edere (Reason for applying for the extension of the right of residence) ______
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Alte date (additional data):

Starea civil (Marital status)___________Apartenena etnic (Ethnic affiliation)___________Studiile (Studies)_______________
Profesie (Profession)____________________Limbi vorbite (Spoken languages)_______________________________________
Grupa sangvin (Blood group)_______________ nlimea (height) ______cm, culoarea ochilor (eyes colour)_________________
Domiciliul n Republica Moldova (residence in Republic of Moldova): raion/ora______________________________________
localitatea____________________str.______________________nr.____bloc_____ap._____tel.________________________
Anterior am avut reedina n Republica Moldova (previous residence in Republic of Moldova) : Da/Nu (se indic perioada)
(Yes/No, period of stay/residence) ___________________________________________________________________________

Lista membrilor de familie care m nsoesc (so, soie, copii, prini)

(List of accompanied family members, spouse, children, parents)

Nume

Prenume

Data
naterii

Gradul de
rudenie

Solicit acordarea
dreptului de edere
n Republica
Moldova: Da/Nu

Domiciliul

Declar, n deplin cunotin de cauz, c toate informaiile furnizate de mine sunt corecte i complete. Am fost informat c
orice declaraie fals din partea mea va atrage refuzul cererii de acordare a dreptului de edere sau anularea/revocarea
acestuia.
(I certify that the information on this application is complete, true and accurate. I was informed that any false information
offered can cause denial of my application for residence)
mi asum deplina responsabilitate ce-mi revine pentru nerespectarea legislaiei privind regimul strinilor n Republica
Moldova.
(I assume all my responsibility in case of not complying with the legislation for foreigners in Republic of Moldova)
Sunt de acord cu prelucrarea datelor prezentate n conformitate cu Legea nr. 133 din 08.07.2011 privind protecia datelor cu
caracter personal
(I agree with processing of data presented in accoding with Law no. 133/08.07.2011 on protection of personal data)

Data (date)____________________
Semntura (signature)