Admission and Residence

MVV issue form

This form is free of charge

Passport photo
35 by 45 mm
(width by height)

1 Personal details
1.1 Surname (family name) |
1.2 S urname at birth |
(previous family name)

1.3 First name(s) (given name(s)) |

Day month year

1.4 Date of birth

Place Country

1.5 Place of birth | |

Current nationality Nationality at birth

1.6 Nationality | |
1.7 Sex Male Female

1.8 Marital status Single Married Separated Divorced

Widow(er) Other (please specify)

1.9 Home address |

1.10 Telephone number(s)
1.11 Email address
1.12 If the applicant is a minor, details of
person excercising parental
responsibility/guardian
| |
|
Surname First name
| |
Address Nationality

| |
No. Valid until

1.13 Are you residing in a country other No Yes. Residence permit or equivalent | |
than the country of your current
nationality?

13BUZ623121|E
 2 van 2

1.14 Type of travel document Ordinary passport Diplomatic passport Service passport Official passport

Special passport Other travel document (please specify)

Number of travel document Date of issue

1.15 Details of travel document |

Valid until Issued by

2 Purpose of stay in the Netherlands

2.1 Employment Employment Self-employment Employment as highly skilled migrant

Highly educated migrant seeking employment EU Blue card holder Start-up

Employment as researcher Employment as cleric/teacher of religion

2.2 Family Live with partner Live with spouse or registered partner Live with parents

Live with adoptive parents Live with foster parents

Family life under art. 8 ECHR Other humanitarian grounds

2.3 Study Study Working holiday programme/scheme and YWEP, Australia, Canada, New Zealand, South Korea

Work placement/learning on the job Cultural exchange, secondary school pupils

Au pair Medical treatment Wealthy foreign national

2.4 Other
Readmission to the Netherlands, previously lived in the Netherlands Resettlement/quota refugee

Day month year

2.5 Date of intended departure

for the Netherlands Name

2.6 Name and address of your |

host in the Netherlands Address

|
Yes No
2.7 Has your host applied for your
MVV with the Immigration and
Naturalisation Service (IND) in
the Netherlands?
I will pay the fees myself My host will pay the fees N/A (no fees due)
2.8 If not, who will pay the
MVV fees into the IND’s Dutch
bank account?
Yes No
2.9 If your host is not a Dutch national,
is he/she an EU, EEA or
Swiss citizen living in
the Netherlands?
Yes No
2.10 Have you previously applied for
an MVV?
Yes No If you have answered Yes: please explain in writing on a separate sheet
2.11 If so, are there any new facts/
circumstances?

3 Signature
I have completed this form truthfully. I am aware that the personal details I have provided will be passed on to
3.1 Please tick the box below official agencies in the Netherlands, which require this information in order to implement the Aliens Act 2000.
Place Day month year

|
3.2 Place and date

|
3.3 Signature

> If the applicant is a minor, the signature

of the person exercising parental
responsibility/guardian