Mu N - 11

N NGH CP, B SUNG, SA I TH THC, GIA HN TM TR (1)

Application for visa renewal, replacement or modification, length of stay extension
(dng cho ngi nc ngoi ang tm tr ti Vit Nam)
To be completed by foreign non-permanent residents in Viet Nam

1- Ngi lm n /Details of the applicant:

H tn (ch in hoa): ......................................................................................Gii tnh: Nam  N 
Full name (in block letters)

Sex

Male

Female

Sinh ngy .......thng ........nm ..................Quc tch: .....................................................................

Date of birth (day, month, year)

Nationality

H chiu s: .........................c gi tr n ngy ......./......../........... Ngh nghip: ..... .......................

Passport number

Expiry date (day, month, year)

Occupation

Ngy nhp cnh Vit Nam:.................................. Mc ch nhp cnh: ................................................

Date of latest entry

Purpose of entry

a ch tm tr Vit Nam: ...............................................................................................................

Current residential address in Viet Nam

in thoi lin h /Contact telephone number ..........................................................................................

2- C quan/ t chc hoc thn nhn Vit Nam mi, bo lnh:
Details of the receiving, sponsoring agency/employer or guarantor in Viet Nam

- C quan, t chc: tn /Name of the receiving, sponsoring agency/employer ....................................................

a ch /Address ...............................................................................................................................
in thoi lin h /Contact telephone number .........................................................................................
- Thn nhn: h tn ................................................................... Ngy sinh: .......................................
Full name of the guarantor (a relative of the applicant)

Date of birth (day, month, year)

Giy chng minh nhn dn/ h chiu/ th thng tr s: .....................................................................

Identify card/ Passport/ Permanent Residence Card number

Cp ngy: ....................................c quan cp: ...............................................................................

Date of issue

Issuing authority

Quan h vi ngi lm n /Relationship to the applicant .........................................................................

a ch thng tr/ tm tr ti Vit Nam: ...........................................................................................
Permanent/ temporary residential address in Viet Nam

in thoi lin h /Contact telephone number .........................................................................................

3- Ni dung ngh:
- Cp th thc:
mt ln  nhiu ln  c gi tr n ngy: ............/........../.....................
Entries requested

Single

Multiple

Validity to (day, month, year)

- B sung, sa i th thc / Visa modified as: ..........................................................................................

- Gia hn tm tr n ngy: ........../............/.....................
Length of stay extended to the date (day, month, year)

- L do /Reasons for the request: .............................................................................................................

4- Nhng iu cn trnh by thm /Additional explanations: .....................................................................
......................................................................................................................................................
...................., ngy......thng.......nm.............
Xc nhn (2) /Certified by
(k, ghi r h tn, chc v, ng du)
Signature, fullname, title and seal

Place and date (day, month, year) of the application

Ngi bo lnh /The sponsor
Ngi ngh /The applicant
(k, ghi r h tn)
(k, ghi r h tn)
Signature and fullname
Signature and fullname

hi ch Note on the mark (1), (2):

(1) Mi ngi khai 1 bn, km h chiu gi trc tip n c quan qun l xut nhp cnh.
(To apply, please submit a completed application form anclosed with his/her in peron at the Immigration Office).
(2)Xc nhn ca th trng c quan, t chc mi, bo lnh hoc ca Trng cng an phng, x ni ngi bo lnh thng tr.
(Certification is given by the chief of the receiving, sponsoring agency/organization of the applicant or of the Chief Police of the
Ward/Commune where the sponsor resides).