Form V.

2013

++AR*fEtrtr*iE+
WsaApplication Form of the People's Republic
t+
IH'
of China
(For the Mainland of China only)

Hlt&ilfrfr*. Ef. ilf;reil5*tffi. ilEtr&SHltE +t*Xt*-+fflflt[il5, ilft tr frff./E#" rE€'*tr H

TEH, ilE "Ttr'
" Tlre applicant shoutd fitl in this form truthfully , completely and clearly. Please type the answer in capital English
Ietters in the space provided or tick (r[ the relevant box to select. If some of the items do not applv. please tvpe NIA or None.
illEEflE[ Date of Pickup tr t4fIfEE The 4th working day E;SfIfFE The 3rd working day EI A2+-flFE The 2nd working day

-. + {H,E part 1: Personal Information

ffi Last name
1.1xyw.&
Full English name I First name ffift-rKiEfiEffiefr, &eH
as in passport
ftffipefrffiffiH.
ffiHltnoto
#tEt8 rrioate name Affir one recent color passport
photo (full face,front view,
1.2+y#.& 1.3 friJ€&gH& bareheaded and against r plain
Name in Chinese Other name(s) light eolored background).

l.4EXtJSex UEM niF l.s ueEH

DOB(yyyy-mm-dd)
1.6r[,aE# 1.7 gAE# Former nationality(ies)
Current nationality(ies)
1.8 s&*H(fi. €D[. E)
Place of birth(city, province/state,country)
t.e g&|fr.t^Riff€E
Local ID/ Citizenship number

1.10 tF ffi /iE fi iE {+# # Passport/Travel document tr ,l.tDiplomatic A ServiceorOfficial

type X grE ordinary tr ^*,'E'E
tr X,fUiE,f+(iHifi,BE) otner (Please specify):

1.11Fffi€6q t.t2 &F.Bffi

Passport number Date of issue(yyyy-mm-dd)
1.13 sts&,fi 1.14
Place ofissue Date^fr8ffi
of expiry(yyw-mm-dd)

tr
tr Bfr/rEfri,LE Former/incumbent member of parliament
ffi,r\ Businessperson
IH& Position
tr e\EHE Company employee
tr
tr Efr/r[fr&tstsE Former/incumbent government
iFe,/r.E Entertainer
oIIiciaI
tr I /Zt R IndustriaUAgricultural worker H& Position
tr SS, stuaent
1.15 EBfrHTIT tr+A Military personnel
(Etfr*fi> tr **Lft Crewmember
H'(t Position
Current tr HE Se[-emptoyea
occupation(s) tr 1FWffi6:g,LR NGO staff
7E!L Unemployed
tr *#z\t Religious personnel
tr iBfr Retired
tr #m,[ IL E staffof media

tr S'f&(iHifi EE) other (Please specify):

I.16 E#H'EH A ffifr,+. Postgraduate tr t+ college

Education n N'f&(€iflEE) Other (Please specify):

&ffi H6Eif;
Name Phone number
1.17rfF+.,{i/+&
Employer/School
fiE&ffi6q
i&fil Address
Zip Code

f rE *4 E /Pam 10f 4
1.1s xE{ttt 1.1e frB&ffifiS
Ilome address ZipCode

1.20 Ei*/+ilt L21E?HFffi

Ilome/mobile ohone number E.mail address

l.l}ffiffitrtnMaritalstatus tr BffiMarried tr B9Singte tr X,fU Other(Plersespeciff):

ft€ Name Plffi Nationality Hlk occupation JtF Relationship

1.23 }EAEfrE
(m{8. ra. J.€
+,61fr#)
Majorfamily
members (spouse,
childrenrparentsret
c.rmay type on
separste paper)

r.24 trE +fr

FAffi#/\trE Name Mobile phone number
Emergency 5+H BtX.6
Contact Relationship with the applicant
1.2s +i# +tF$firfffiEffiElafretr country or territory where the
applicant is located when applying for this visa

-, ift6H,H. Part 2: Tlavel lnformation

tr B'Arb'l{ olliciatvisit tr HHfl't. firF. EhAq,LF
As resident diplomat, consul or staffof international
tr iEffi Tourism (L) organization
D tifi. AH. *1":l Non-businessvisit(F) D i<LEW As permanent resident @)
a ffilLHA Business & Trade (M) tr IfF Work(Z)
tr AtrBlE As introduced talent @) tr 6# As child in foster care (Ql)
a ffift#'* As crew member (C)
tr i$fr Transit(T)
2.1+H
n Effi#H+ Ea\R*#tE tr Elzll.EgE#Et tr 5trEa\R*#tA+E n<,'BBfr&Hirt EIA
,l' El z\ Short-term visit to Chinese citizen or XfrWmEWffiit rao E Family reunion for over
.\H$H ttlaior
foreigner with Chinese permanent residence status 180 days with Chinese citizen or foreigner with
purpose
(Q2) Chinese Dermanent residence status (Ql)
ofyour visit
tr EffiffiEtrAfF. +Z+Sf;A+EItrBEBf! tr &ffiHEtrTfF. +E+SHE+ EIEB HT'I. EIA
,1. El ,l\ Short-term visit to foreigner residing in As accompanying family member of foreigner
China due to work study or other reasons (S2) residinc in China due to worh study or other reasons (Sl)
tr ffiffi+X Short-term siudy for less than 180 tr &ffi+Z Long-term study for over 180 days (X1)
davs (X2)
tr EffiXU'ffirE as journalist for temporary news n fl' El H & + EI # Hl ftf iE# As resident iournalist (J1)
coverage (J2)
n H'f&(tHi[EE)other (Please specify):

! -n( H &tsz E E 3 + EAX) One entry valid for 3 months from the date of issue
2.2 *fi! tr :n(H & HZAfu 3-6 + Fd N' TWo entries valid for 3 to 6 months from the date of issue
A ++*lR ( HSHZEE 6 +EHX) Multiple entries valid for 6 months from the date of issue
^.&Iifi
Intended number
a -+*lR ( ESHZEE | +AN) Muttiple entries valid for I year from the date of issue
ofentries
tr H{& (iHi[q) Other(Please specify):
23 EA+iFfrgRW* Are you applying for express service?
E, IEAW*fr6fi$B'8ft8, ArE'&fiH. Note: Express service needs approvrl of trEYes D6No
consular oflicials, and extra fees may apply.

2.4 *t.frffifriiE nilfrE+ EI ffi E tr

Expected date of your first entry into China on this trip (yyyy-mm-dd)

tf2 rt4E lPrtezof4

2.s m+ffi E + +tR&4,t+WEi &&x& Days
Longest intended stay in China among all entries

Effi Date HfrfrtL Detailed address

2.6 E+Eq6{f
E (&r.llflflnF,
EPItEfrHS)
Itinerary in
China (in time
$equence, may
type on separate
paper)

2.7 ##E.flE + El H tf, Bt fi ffi ? who will pav for vour travel and
expenses during your stay in China?

w.&*,ef$
Name

2.s +Etfr^urH
trft
Address
+{ufr+/\EB
Information of
inviter in China
H6Eif;
Phone number

5+iF^re6
Relationship with the applicant

2. e E6 E %*€)t + El Sir ? tu A', iFfi H EiE-n#?S + EI Slr Ft r.t

14 fl ffi.H " Have you ever been granted a Chinese visa? If applicable,
please specify the date and place of the last time
you granted the visa.
were

you visited in the last 12 months

=. t'fd$E Part3: Otherlnformation

3. I EE gE+ Eflli$Sfi*EBi+EJrD j,f HTHEHB ? Have you ever overstayed your visa or
trE Yes trE No
residence permit in China?

3.2 EE9#.&frfrs.H+ El#!T, 4&ffifrtrAF El? Have you ever been refused a visa for China, or
trE Yes tr6 No
been refused entry into China?
3.3 E6E+EI*X,{UElAArE,qEif,*? Do you have any criminal record in China or any other
trE Yes tr6 No
countrv?

OFEffi#HE Serious mental disorder

trE Yes fl6 No
@++*trffi *&ffi Infectious pulmonary tuberculosis
@6 HEfr Ba\*L& EtH'f&&*ffi Other infectious disease of pubtic health hazards
3. 5 ,f 30 E E6BfrAtrffiFttEffi&*Hi El*fi&tr ? Did you visit countries or territories affected
by infectious ^diseases in the last 30 days?
lEYes DE No

3.6fuxrf 3.1 sll 3. s Hi{rf,I-+l6JEE# '8", iFETmi+fru,qE.

Ifyou select Yes to any questions from 3.1 to 3.5, please give details below.

$ 3E ,t 4 E' / Paqe 3 of 4
 3. 7fr xa ***#e nr ffi + n pfit F!{,fu5#ilT + iFiH rf ffi +rfi , iHEft &E mfi, qE .
If you have more information about your visa application other than the above to declare,please give details below or tytrre on a
separate paper.

3. 8 r[F]H/\Fffi+B!'lHtr 5+tHz\-FJffifr, iFB'lHtrz\ffi,HffiflfiEIEFF.HM'I?LH,B. rf someone else travels and shares

the same passport with the applicant , please alfix their photos and give their information below.

M'tiL 1 {E'tiL 2 M',iiL 3

Person I Person 2 Person 3

1HfiAE,E
Information triMffi,tfrfr trt#ffi.trftfr ffiMffi.trft
Aff*Photo Afftx Photo Atfrx Photo
here here heru

*a
Full name
&i'J
Sex

4E
DOB(yyyy-mm-dd)

W, FWN&& lart4: Declaration &

4. I fi F EE, A E mi*#E ffiM#ffid fr*E*, f Effi trHfr trHfl + iHfr#l HtE*&fi " fr-tn*Htr *
I hereby declare that I have read and understood all the questions in this application and shall bear all the legal consequences for the
authenticity of the information and materials I provided.
4. 2 frfrffi BAA#6SiT. #€Effi enT, AHnry V&A Nffi tr gH+B H fi SB E
, , &8,
E'|EI6*' i,F+4854 ft*fr
E[BE-+*&nr + Hitfr €*&F4fr + gt "
I understand that whether to issue a visa, type of visa, number of entries, validity and duration of each stay will be determined by
consular official, and that any false, misleading or incomplete statement may result in the refusal of a visa for or denial of entry into
China.
4. 3 &&ffi , &E+ EIr}H,'FH/\Ep&#A^+ El#ff ffiAfr ffi&fr&^&"
I understand that, according to Chinese law, applicant may be refused entry into China even ifa visa is granted.

i +if,l.*e
Applicant's signature:........

*l' *ffi18ElHi*fr+^^frf'€.4H*ez\ft$" Note:Theparentorguardianshallsignonbehalfofaminorunder18yearsof

E. ,f&,/\ftlH FiH*f.tHE DJT ru * Part 5' If the application form is completed by another person on the
IilI out the int-ormation of the one who com the lorm
5.2 5 +tFl\*.6 Rehtionship
5.1ft€ Name
with the applicant

5. 3 &tl Address 5.4 tlifr Phone number

5. 5 FqE Declaration
&F H +/r'E&E F iH z\* *ffi fir'Er E*,
iI BE + iH,,\ effi *ffiil#.+ rf H 5 fi A Wffi fiit.
I declare that I have assisted in the completion of this form at the request of the applicant and that the applicant understands aud
agrees that the information provided is true and correct

ftHz\S€lsignature: El Sl/Date (yyyy-mm-dd):

4E *48 lPsse4ol4