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Application for an extension of stay (limited leave to remain)

Request for Urgent Treatment


• Once you have completed this form please fax it to 0114 207 6017

Details of Application
Surname/family name or applicant
First names
Nationality
Date of birth
Passport number

Contact name & address as stated on


Question 1, Page 1 on the FLR(IED) form

Date the application was sent to payment processing


centre
The method of payment

The recorded or special delivery post number


(if the application was delivered by courier, please supply their
name & delivery number)

The address to which all correspondence and documents


should be returned

The FLR(IED) payment reference number LT


Contact telephone number
Email address

Reason for Urgent Treatment


Commencing Employment Start Date
Bereavement Date required by

Other, please state reasons: Date required by

Signature

Your signature Date

Print Name Tel No.