Mu (Form) NA17

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

ngy 05 thng 01 nm 2015Tn c s lu tr: (1)a ch:..in thoi:.... CNG HA X HI CH NGHA VIT NAM

c lp- T Do- Hnh phc ., ngy.thng..nm

PHIU KHAI BO TM TR CHO NGI NC NGOI

Knh gi: .STTH TnGii tnhSinh ngy, t thng, nmQuc tchLoi, s h chiu

(2)Loi, thi hn, s, ngy cp, c quan cp th thc

(3)Ngy, ca khu nhp cnh

(4)Mc ch nhp cnh

Tm tr (t ngy n ngy)

NamN

Xc nhn (ca n v tip nhn)i din c s lu tr(K, ghi r h tn)

Ghi ch:Gi hng dn ghi ti liu: 0946639599(1) C s lu tr du lch, nh khch, khu nh cho ngi nc ngoi lm vic, lao ng, hc tp, thc tp, c s khm bnh, cha bnh, nh ring, hoc c s lu tr khc theo quy nh ca php lut.

(2): Ghi r s, loi h chiu (ph thng, cng v);

(3): Nu nhp cnh theo din min th thc th ghi Min th thc; nhp cnh bng giy t khc th ghi r theo th t: loi giy t (th thc, th tm tr, giy min th thc, th ABTC), s, thi hn, ngy cp, c quan cp.

(4): Ghi ngy, thng, nm, ca khu nhp cnh ln gn nht;