Application

for Verification against EU Law

(certificate of lawful residence)
Nederlandse versie
Dit aanvraagformulier is ook verkrijgbaar in het Nederlands. Bel met
0900 1234561 ( 0.10 p.m. plus de kosten voor het bellen met uw
mobiele telefoon). Vanuit het buitenland belt u +31 20 8893045. Of kijk
op: www.ind.nl om dit formulier aan te vragen of te downloaden.
Please read the explanation on this page and the next carefully before you fill in the form.
Why this form?
This form is intended for:
1. Nationals of Bulgaria and Romania, and
2. Family members and relatives of nationals of the Union who are not
nationals of the EU, EEA Member States, or Switzerland themselves.
Nationals of the Union are nationals of the EU Member States. Nationals
of the EEA Member States and Switzerland are considered equivalent to
EU nationals. Although Dutch nationals are nationals of the Union as
well, family members and relatives of Dutch nationals usually cannot use
this form (see the explanation on page 2).
Nationals of Bulgaria and Romania
If you originate from Bulgaria or Romania, you can use this form to
submit an application for verification against EU Law and to request the
issue of a certificate of lawful residence. You are not obliged to apply for
this certificate of lawful residence. If you want to be entitled to use social
security benefits in the Netherlands, it is advisable to submit an
application for verification against EU Law. The certificate of lawful
residence is valid for a maximum period of five years.
Family members and relatives of nationals of the Union who are not
nationals of the EU, EEA Member States, and Switzerland themselves.
If you are a family member or relative of a national of the Union and you
yourself are not a national of one of the countries mentioned above,
then you must use this form to submit an application for verification
against EU Law and to request the issue of an EU residence document for
the purpose of staying with a national of the Union (your sponsor).
You are obliged to submit an application for verification against EU
Law, as you must be able to prove that you have lawful residence in the
Netherlands, and you must state your purpose of stay. The certificate of
lawful residence is valid for a maximum period of five years. The national

of the Union with whom you are staying must prove himself/herself that
he/she has lawful residence in the Netherlands, and must state what
the family relationship with you is. This can, for example, be done by a
certificate of lawful residence, a declaration of registration at the IND, or
a permanent residence document for nationals of the Union. If he/she
does not have this proof, he/she must prove that he/she has lawful
residence in the Netherlands by means of other evidence and
documents.
How to fill in this form
Use one form for each person for whom an application is being
submitted. The form consists of 4 pages and 3 Appendixes. Whether you
have to fill in an appendix depends on your situation. So, first determine
which purpose of stay applies to you. Do not submit this form until
you have filled in this form completely and collected all the required
evidence and documents, so not in parts. If your application is not
complete it cannot be assessed properly. Non-payment or overdue
payment and the submission of an incomplete application may slow
down the handling of the application.
Minor children
If you are the parent or representative of a minor child, you can also fill
in this form on behalf of him/her. Where the form refers to you or the
applicant, the child is meant. Please answer all questions on behalf of
the child and enclose all the required evidence and documents.
Children who are 12 years of age or older must sign the form himself/
herself. Fill in one form for each child.
How to submit this application
Before you submit the application, call 0900 1234561 ( 0.10 per
minute plus any additional costs charged by your operator if you are
calling from a mobile phone) to make an appointment with the IND
desk in your region. The IND employee will tell you which information
you must bring with you to the appointment. Each person submitting an
application must be present when the application is submitted.
Original documents
You must bring the originals of all the required evidence and documents
with you. The IND verifies these documents and makes copies of them,

Signature of the applicant

I am applying for verification against EU Law and for the issue of a certificate of lawful residence for me/my child/the child I legally
represent. I have filled in this form truthfully. I know that, for the purpose of implementing the Aliens Act 2000, the personal data
filled in will be processed and passed on to the institutions that require these details for this purpose. I will immediately inform the
IND of any changes in my situation or the situation of the foreign national that relate to the right of residence.

Name

|
City/Town

City/Town and date

month

year

Signature

Day

| | I submit this form and

IND5005_M35E/13A

Number

of appendices/documents in evidence

2 of 4

after which the IND will return all original documents to you. The copies
will be added to your application.
IND desks
The IND has desks in Zwolle, Utrecht, Rijswijk, Den Haag, Rotterdam,
Eindhoven, Den Bosch, Amsterdam, and Hoofddorp. These are the cities/
towns where you must submit your application. Please visit www.ind.nl
for the nearest IND desk.
Nationals of the Union
Nationals of the Union are nationals of the following countries:
the EU Member States: Austria, Belgium, Bulgaria, Cyprus, Czech
Republic, Denmark, Estonia, Finland, France, Greece, Germany,
Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the
Netherlands, Poland, Portugal, Romania, Slovenia, Slovakia, Spain,
Sweden, and the United Kingdom.
the EEA Member States: Liechtenstein, Norway, and Iceland.
Switzerland.
Exception: Dutch nationals
Although Dutch nationals are also nationals of the Union, you cannot
use this form if you want to stay in the Netherlands as a family member
or relative of a Dutch national. There is one exception to this, namely:
You are a family member or relative of a Dutch national; and
The Dutch national with whom you wish to stay resided previously
in another EU/EEA Member State or in Switzerland under EU Law (as
an employee, a self-employed person, a student, or an economically
non-active person); and
You stayed with the Dutch national in the other EU/EEA Member State
or in Switzerland, and
The Dutch national currently lives in the Netherlands again.
If this exception applies to you, you can still use this form.
Application costs (charges)
Applying for certificate of lawful residence costs money. These costs must
be paid the moment you submit the application. The costs depend on
the purpose of stay for which you submit an application. This form does
not include any information about the costs or a possible exemption
from paying charges. If you want to be informed of the costs in advance,
please visit www.ind.nl or call 0900 1234561 ( 0.10 per minute plus
any additional costs charged by your operator if you are calling from a
mobile phone). If the assessment of your application shows that you do
not qualify for the requested certificate of lawful residence, the money
will not be refunded.
New passport photo, signature, and Appendix Photo Card
This form must be accompanied by a Photo Card, which is necessary for
making your residence permit. Please place your colour passport photo
and your signature on this Photo Card. The passport photo will be placed
on a chip on the residence permit. Your signature will also be included
on the residence permit.
Requirements of the colour passport photo
Your colour passport photo, which you must place on the enclosed
Photo Card, must meet the following requirements:
Your passport photo may not have been used for a residence permit
before and it must bear a clear resemblance.
In addition, your passport photo must meet the Dutch passport
requirements. You can find these requirements at
www.paspoortinformatie.nl/nederlands/reisdocumenten/pasfoto.
If your passport photo does not meet these requirements, it will not be
possible to make a residence permit and issue it to you. So it is important that you send along a proper passport photo. Always have a new passport photo made by a professional photographer who is familiar with
the applicable requirements for passport photos in the Netherlands.
Signature requirement
Each person from 12 years or older must place his/her signature on the
Photo Card himself/herself.
Bring the Photo Card along when you are submitting your application.

Border-crossing document
When you are going to submit your application, you must also bring
along your border-crossing document (e.g. your passport). A sticker will
be affixed to this document and a copy will be made of it. This copy will
be added to your application.
What will happen with your application?
Once you have submitted your application at one of the IND desks
and you have paid the application costs (charges), your application
will be assessed by the IND. If your application is not complete it cannot
be assessed properly. Non-payment or overdue payment and the
submission of an incomplete application may slow down the handling
of the application. According to the law, the IND must make a decision
on your application within 6 months. You will receive a written notice
when the handling of your application has been completed. When your
application is granted, you will receive a letter with information about
where you can pick up your residence document.
Foreign documents
Any official foreign documents about persons that are required for
the application must have been legalised or provided with an Apostille
stamp by the competent authorities of the issuing country.
This may relate to documents such as birth certificates, certificates of
unmarried status (not older than 6 months), marriage certificates,
and court decisions regarding adoption and guardianship.
This may take a great deal of time. We therefore advise you to have the
relevant documents legalised or provided with an Apostille stamp in
the country of origin several months before submitting the application.
For more information about legalisation or Apostille requirements
for documents for each country and any exceptions to this, please call
the public information line of the Ministry of General Affairs at
+31 77 465 6767, or at 1400 from inside the Netherlands, or send an
e-mail to info.consulair@minbuza.nl or see www.rijksoverheid.nl.
Language of the documents to be enclosed
All documents must have been drawn up in Dutch, English, French,
or German. If this is not the case, you must have your document(s)
translated by a translator who has been sworn in as a translator by the
Dutch court. Hand in the translation(s) of the document(s) together
with the application at the IND desk. If you do not have the document(s)
translated in the Netherlands by a translator who has been sworn in as a
translator by the Dutch court, but abroad, not only the document,
but also the translation must have been legalised or provided with an
Apostille stamp by the competent authorities of the issuing country.
Work permit
If you want to work as an employee, you will often need a work permit.
For more information, please contact UWV WERKbedrijf (which is
the work placement division of the Netherlands Employees Insurance
Agency) at www.werk.nl.
Personal Data Protection Act
The Personal Data Protection Act (Wbp) places an obligation on the IND
to inform you that the IND is the organisation which processes the data
in your application. The IND does this to be able to process your request
or application. If you have any questions regarding the data processing
procedure you can submit them in writing to the IND, Postbus 287,
7600 AG Almelo. This is the department you must contact if you would
like a summary of your personal data held on file. Following a request
for such a summary you can ask to have your personal data changed,
removed or blocked.
More information
Please call the IND for more information about this application form
or about your situation. The IND can be reached at 0900 1234561 on
working days from 9 a.m. to 5 p.m. ( 0.10 per minute plus any additional costs charged by your operator if you are calling from a mobile
phone). From abroad, please call +31 20 889 3045, or visit: www.ind.nl.
You can also go to one of the IND desks. If you want to know where the
nearest IND desk is, please visit www.ind.nl or call 0900 1234561 ( 0.10
per minute plus any additional costs charged by your operator if you are
calling from a mobile phone).
IND5005_M35E/13A

Application
1

3 of 4
for Verification against EU Law (certificate of lawful residence)
Immigration and Naturalisation Service
Ministry of Security and Justice

Details of the applicant (holder of the residence document)

1.1 Do you have a V-number? n Yes

n No

1.2 Citizen Service Number

(BSN) (if known)

Surname as it appears in your passport or on your identity papers

1.3 Name

| |

1.4 Gender

n Male n Female

(The V-number can be found in previous correspondence

from the IND or on your previous residence permit )

First names

Street

Number

1.5 Home address

Postal code

Day

1.6 Date of birth

1.7 Place of birth

1.8 Country of birth

1.9 Nationality

1.10 Civil status

month

City/Town

year

Telephone number

1.11 Contact

E-mail

Purpose of stay in the Netherlands

Please state below the specific reason for applying for a certificate of lawful residence and follow the instruction written there.
Tick the most important reason. You may not tick more than one reason for your stay. If you tick more than one reason, your
application will only be assessed on the reason ticked first.

> You have Bulgarian or Romanian nationality

n Work as an employee for a period of more than 3 months (431)
Your application must be accompanied by the following supplementary evidence
and documents:
The Appendix Employers Declaration filled in and signed by your employer
(this declaration may not be older than 3 months);
A (copy of the application) for a work permit or a copy of the work permit
itself (see the explanation on page 2 of this form).
n Work on a self-employed basis (432)
People who work on a self-employed basis must prove that they have come
to the Netherlands to perform work different from work as an employee,
for example, on the basis of a (recent) in the Commercial Register of the
Chamber of Commerce.
They must also prove that it concerns real work. This may, for example, be
proved on the basis of a balance sheet, a profit and loss account, and
monthly statements of business results, and, if these are not yet available,
on the basis of a statement or a projection drawn up by a chartered
accountant or a recognised financial advisor. Also copies of invoices, bank
statements showing that the bills are paid, VAT payments and tax returns
should be submitted.
n Services provider (431)
Your application must be accompanied by the following supplementary evidence
and documents:
Evidence showing the duration of the services to be provided;
If a work permit is required in the services providers country of
establishment, a copy of the work permit evidencing that you are authorised
to perform work as an employee of the services provider.

n Recipient of services (437)

Your application must be accompanied by evidence showing the service to be
received (e.g. legal services).
n Study (439)
Your application must be accompanied by the following supplementary evidence
and documents:
The certificate of registration at the educational institution stating which
course is being taken by you;
Evidence showing that you have sufficient means of existence for the
duration of your stay. This may be your own declaration or a declaration
from a third party;
Evidence showing that a health insurance policy has been taken out in your
name (e.g. an insurance card or a health insurance policy).
n Economically inactive person (437)
Your application must be accompanied by the following supplementary evidence
and documents:
Evidence showing that a health insurance policy has been taken out in your
name (e.g. an insurance card or a health insurance policy);
Evidence showing that you have sufficient means of existence for yourself
and your family members to prevent you from depending on public resources
This may include means of your spouse, partner, registered partner, or a
third party, provided that they are not public means and that you have free
disposal of or an entitlement to payment, whether periodically or otherwise.
Examples include a recent statement of a joint bank account (in Dutch
referred to as an en/of rekening) showing the partners income. In case of
a marriage or a registered partnership, a recent salary slip of the partner will
suffice.

IND5005_M35E/13A

4 of 4

> You are a family member of a national of the Union / You are a family member of a
national of the Union and you yourself do not originate from the EU

n Y
 ou are the spouse, partner or registered partner of a national of the
Union (and you yourself do not originate from the EU) (740, 741, 746, 747,
748, 753, 754, 755, 760)
Your application must be accompanied by the following supplementary evidence
and documents:
The document issued by the competent authorities evidencing the marriage
or the registered partnership (see the explanation Foreign documents and
Language on page 2 of this form);
A copy of the certificate of lawful residence of your sponsor;
Evidence showing that your sponsor (still) has income from work or other
sufficient means of existence in order to prevent your sponsor and his family
members from depending on public resources.
In case of a relationship, your application must also be accompanied by
Evidence showing that you have a long-lasting relationship with the EU
citizen. This is shown by the fact that you have run or recently ran a joint
household for a period of six months. If this joint household is not run, or
has not been run in the Netherlands, you can prove this by:
- proof that you cohabited abroad. The following documents may be
submitted for this purpose: a certificate of registration at a municipal
administration office, tenancy agreements, sales agreements of a house
inhabited jointly, or bank statements in both names; or
- a birth certificate showing that a child was born from your relationship
The Appendix Declaration of Relationship for Partner of EU National filled
in completely and signed by you and your sponsor; or
A copy of the certificate of lawful residence of your sponsor.
n Y
 ou are younger than 21 years of age and you are the child or grandchild
of a national of the Union or his/her spouse, partner or registered partner
(and you yourself do not originate from the EU) (742, 749, 756)
Your application must be accompanied by the following supplementary evidence
and documents:
The document showing the family relationship (see the explanation Foreign
documents and Language on page 2 of this form).
A copy of the certificate of lawful residence of your sponsor.
Evidence showing that your sponsor (still) has income from work or other
sufficient means of existence in order to prevent your sponsor and his family
members from depending on public resources.
NB. A child or grandchild of the unmarried partner (so not a registered partner)
of a national of the Union only qualifies for residence under EU Law if this child
is younger than 18 years of age. This situation is also subject to additional
conditions. For more information about this, please call 0900 1234561 ( 0.10
per minute plus any additional costs charged by your operator if you are calling
from a mobile phone).

n Y
 ou are older than 21 years of age and you are the child or grandchild of
a national of the Union or his/her spouse, partner or registered partner
(and you yourself do not originate from the EU) (743, 750, 757)
n You are a family member in the ascending line (parent or grandparent) of
a national of the Union or his/her spouse, partner or registered partner
(and you yourself do not originate from the EU) (744, 751, 758)
Your application must be accompanied by the following supplementary evidence
and documents:
The document showing the family relationship (see the explanation Foreign
documents and Language on page 2 of this form);
A copy of the certificate of lawful residence of your sponsor.
Evidence, for example a declaration issued by the competent authority, showing you received material support to provide in your basic needs in your
country of origin or country of former residence because of your financial
and personal situation.
Evidence showing that your sponsor (still) has income from work or other
sufficient means of existence in order to prevent your sponsor and his family
members from depending on public resources.
n Y
 ou are a relative of a national of the Union, other than a parent,
grandparent, child or grandchild (and you yourself do not originate from
the EU) (745, 752, 759)
Your application must be accompanied by the following supplementary evidence
and documents:
The document showing the family relationship (see the explanation Foreign
documents and Language on page 2 of this form)
A copy of the certificate of lawful residence of your sponsor.
Evidence showing that your sponsor (still) has income from work or other
sufficient means of existence in order to prevent your sponsor and his family
members from depending on public resources.
A declaration - issued by the competent authority - showing that you
received material support from your sponsor while you were staying in your
country of origin or before that.
Evidence, for example a declaration issued by the competent authority,
showing you require material support to provide in your basic needs in your
country of origin or country of former residence because of your financial
and personal situation; or
- a declaration - issued by the competent authority - showing that you
require personal care from your sponsor for serious reasons of health; or
- a declaration - issued by the competent authority - showing that you lived
with your sponsor while you were staying in your country of origin or
country of former residence.

> You are a family member of a Dutch national and you yourself do not originate from the EU
n Y
 ou are a relative of a Dutch national as explained in the Explanation
(and you yourself do not originate from the EU) (761)
Your application must be accompanied by the following supplementary evidence
and documents:
The document showing the family relationship (see the explanation Foreign
documents and Language on page 2 of this form)
A copy of your EU residence document and that of your Dutch sponsor (or where applicable - a copy of your sponsors certificate of lawful residence)
issued by the other Member State or Switzerland
A certificate of registration in the town/city in the other Member State
Other evidence showing that you and your sponsor resided in another
Member State under EU law (e.g. rental agreement, bank statements
showing actual residence in the other Member State and/or mail received
on the adress in the other Member State)

Submitting your application

1. Place your colour passport photo and your signature on the Appendix
Photo Card you will find enclosed with this form. Your passport
photo may not have been used for a residence permit before, it must
bear a clear resemblance, and it must meet the Dutch passport
requirements (see www.paspoortinformatie.nl/nederlands/
reisdocumenten/pasfoto).
2. Check whether you filled in the form completely.
3. Make sure that your application is accompanied by all the enclosures,
evidence and documents that have been requested. Do not use any
staples or paperclips.
4. Now place your signature on the front page of this form.

Submitting this form

First call 0900 1234561 ( 0.10 per minute plus any additional costs
charged by your operator if you are calling from a mobile phone) to
make an appointment to visit the IND desk in your region. You must also
make an appointment if you downloaded this form from www.ind.nl.
Once you have made an appointment, you can hand in the application at
the IND desk.

IND5005_M35E/13A

Appendix
Employers Declaration
M35E

If you have several employers, please copy this appendix. Fill in and sign one copy for each
employer. The application form states in which cases and from which person(s) you must
enclose the Employers Declaration. The employer must have a work permit for employees
with Bulgarian or Romanian nationality. Please enclose this work permit with your

application. NB. The IND may verify the correctness of the enclosed wage, employment and
benefit details at another government agency (e.g. the Netherlands Employees Insurance
Agency (UWV) or the Tax and Customs Administration).

Details of the employee

1.1 Citizen Service Number

(BSN)

Surname as it appears in your passport or on your identity papers

1.2 Name

| |

1.3 Gender

n Male n Female

First names

Street

1.4 Home address

Number

|
Postal code

Day

month

City/Town

year

1.5 Date of birth

1.6 Place of birth

1.7 Country of birth

1.8 Nationality

Details of the company/institution

2.1 Name

|
Street

2.2 Visiting address

|
Postal code

City/Town

2.3 Withholding tax number

Employment details

3.1 Employees job title

|
Day

month

year

3.2 Date of employment

3.3 Type of employment

a. n The duration of the employment agreement is

Day

month

year

from

or n unknown or indeterminate

to

BE02/13A

Day

month

year

Number

2 of 2

or n one year or more (including fixed contract) from

or n more than three months, but less than one year,

Day

month

year

from

Day

month

year

Day

month

year

month

year

to

b. n Secondment work or short term contracts.

Day

Commencement date of current contract

c. n The applicant has worked uninterruptedly for the past 12 months; or

n The income from this work are still available
3.4 Is there a provision for continued
payment of wages during the
term of the agreement if there is
not any work?

n No

3.5 Trial period

n No

n Yes

Day

Hours per week (actual)

3.7 Gross salary (excluding holiday

allowance)

n Per month, or
n Per month, or

3.9 Net salary (excluding holiday

allowance)

n Per month, or

All amounts rounded to the nearest full euro

n per 4 weeks

3.8 Wage for social security purposes

(excluding holiday allowance)

All amounts rounded to the nearest full euro

n per 4 weeks

All amounts rounded to the nearest full euro

n per 4 weeks

3.10 Percentage of holiday allowance

year

n Yes, to

Hours per week (contractual)

3.6 Working hours a week

month

Signature of the employer

I declare that the above-mentioned employee has been employed by the above-mentioned company/institution.
I have filled in this form truthfully.

4.1 Name

4.2 Employees job title

4.3 Telephone number

City/Town

4.4 City/Town and date

4.5 Signature

4.6 Stamp of company/institution

BE02/13A

Day

month

year

Appendix
Declaration of Relationship
for Partner of EU National
M35E
Only fill in this declaration if you are applying for a certificate of lawful residence for
residence with your unmarried partner who is a national of the EU, the EEA, or Switzerland.
Fill in and sign the declaration and submit it together with your application.

Details of the foreign national (the applicant)

1.1 V-number
Surname as it appears in your passport or on your identity papers

First names

1.2 Name

| |

1.3 Gender

n Male n Female
Street

1.4 Home address

|
Postal code

1.5 Civil status

Number

City/Town

|
Day

month

year

1.6 Date of birth

1.7 Place of birth

1.8 Country of birth

1.9 Nationality

|
The applicant declares as follows:
He/she has maintained a long-lasting relationship with the co-undersigned and he/she has run a joint household to this end and has
actually cohabited at the above-mentioned address as from:
Day

month

year

Date
He/she undertakes to inform the Immigration and Naturalisation Service immediately of the termination of his/her long-lasting
relationship with the co-undersigned;
He/she will also inform the Immigration and Naturalisation Service of any other relevant changes in this context

The sponsor (the partner)

Surname as it appears in your passport or on your identity papers

First names

2.1 Name

| |

2.2 Gender

n Male n Female
Street

2.3 Home address

|
Postal code

City/Town

|
BM42/13A

Number

2 of 2

2.4 Civil status

|
Day

month

year

2.5 Date of birth

2.6 Place of birth

2.7 Country of birth

2.8 Nationality

|
The sponsor declares that the undersigned is his/her life partner and that he/she has run a joint household with him/her and has
actually cohabited with him/her at the above-mentioned address as from:
Day

month

year

Date

Signature
I have filled in this form truthfully.
City/Town

3.1 City/Town and date

3.2 Signature of the foreign

national

3.3 Signature of the sponsor

Day

month

year

> Falsely filling in the Declaration of Relationship for Partner of EU National constitutes a punishable offence which will be reported to the police in all
cases.

BM42/13A

Bijlage fotokaart
Appendix Passport Photo Form
The Passport Photo
Stick a new and unused passport photo on the designated frame at the bottom of
this page. If the application is meant for your child, please use a new and unused
passport photo of your child. Your passport photo has to meet the Dutch passport
requirements. Always have your passport photo made by a professional
photographer who is acquainted with the Dutch passport requirements.
No residence document can be issued to you if your passport photo does not meet
the Dutch passport requirements. It is therefore very important to supply a good
passport photo with this form.

De pasfoto
Onder aan deze pagina moet u een nieuwe, nog niet eerder gebruikte
pasfoto van uzelf plakken. Als de aanvraag bedoeld is voor uw kind,
dan moet u een nieuwe, nog niet eerder gebruikte pasfoto van uw kind
plakken. Uw pasfoto moet voldoen aan de Nederlandse paspoorteisen.
Laat daarom altijd een nieuwe pasfoto maken door een beroeps
fotograaf die bekend is met de eisen die in Nederland aan pasfotos
worden gesteld. Als uw pasfoto niet aan de Nederlandse paspoorteisen
voldoet, kan er geen verblijfsdocument aan u worden uitgereikt. Het is
dus belangrijk dat u een goede pasfoto meestuurt.

How to append a photo to this form?

Pull away the paper cover, start at the arrow;
Place your photo straight on the grey area below;
Tightly press the photo on the paper;
Place your signature within the frame on the lower left side.
Use a pen with dark, preferably black ink. If your signature is not clearly
visible, a residence permit can not be created.

Hoe plakt u de foto op dit formulier?

Trek het niet-plakkende vel papier los, begin bij de pijl;
Leg uw foto recht op het grijze kader;
Plak de foto en druk stevig aan;
Zet uw handtekening in het vak linksonder. Doe dit met een pen
met een donkere kleur inkt, het liefst zwarte inkt. Als uw handtekening niet duidelijk is, kan geen verblijfsdocument worden gemaakt.

> Invullen in blokletters Complete in capital letters

1.

Voorna(a)m(en) en achternaam
First name(s) and surname

2.

Woonadres
Home address

|
Straat Street

|
Postcode Postcode

3.

Geboortedatum
Date of birth

4.

Nationaliteit
Nationality

5.

V-nummer
V-number

6.

Handtekening
Signature

Nummer Number

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IND4014_BE04/12A