Mu (Form) NA17

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

ngy 05 thng 01 nm 2015

CNG HA X HI CH NGHA VIT NAM

Tn c s lu tr: (1)
a ch:..
in thoi:....

c lp- T Do- Hnh phc

., ngy.thng..nm

PHIU KHAI BO TM TR CHO NGI NC NGOI

Knh gi: .

STT

H Tn

Gii tnh Sinh ngy,

t thng,
Nam N
nm

Xc nhn
(ca n v tip nhn)

Quc tch

Loi, 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)

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;