Mu ( Form) N12/M

PHIU KHAI BO TM TR
REGISTRATION CARD OF STAY
Tn khch sn/ nh ngh/ nh khch/ nh ring: ( 1)
MOTEL PHUNG NG
Name of the Hotel/ Guest house/ private house
S nh
05B
ng/ ph/ thn KDC 2 - p 5
phng/ x Ph Vinh
House No
Road/ Strt/ Village
Ward/ Commune
Qun/ huyn nh Qun
thnh ph/ tnh
ng Nai
District
province/ City
in thoi/ Telephone number: 061 3 612 092

PHN KHAI CA KHCH

FOLLOWING ITEMS ARE FILLED BY THE TENANT
1. H v tn (Ch in hoa):..

2. Gii tnh: Nam

N
Full name ( in block letteris)
Sex
Male
Female
3. Sinh ngy..thng..nm.. 4. Quc tch:
Date of birth (day, moth, year)
Nationality
5. Ngh nghip:. 6. S h chiu:
Occupation
Pasport Number
7. Ngy nhp cnh: ./...../.. 8. Ca khu nhp cnh:.
Date of entry ( day, month, year)
Port of Entry
9. Mc ch nhp cnh:..........................................................................................
Purpose of entry
10. c php tm tr ti Vit Nam n ngythng nm...
Length of permitted stay in Vietnam until (day, month, year)
11. S th tm tr/ Th thng tr (nu c) s: ..
Temporary/ Permanent residence Card number (if any)
12. Ngh ti khch sn/ nh ngh/ nh khch/ nh ring: (1)
MOTEL PHUNG NG
Staying at Hotel/ Guest house/ Private house
t ngy/../. n ngy....//
13. Tr em di14 tui i cng (H tn, gii tnh, ngy sinh, quc tch, s h chiu):
Accompanying children under 14 years old (Full name, sex, date of birth, nationality, passport No)
...................................................................................................................................................
...
nh Qun, ngy thng . Nm ..
Place and date of declaration (day, month, year)
Khch k tn
Signature

.
Ghi ch Note on the mark ( 1):
(1) Nu nh dn th ghi h tn ch nh.
In the case not staying at a Hotel or Guesthouse, please state the landlord of accommodation