1.18 家庭住址 Home address 1.19 邮政编码 Zip Code 1.20 电话 / 手机 Home/mobile phone number 1.21 电子邮箱 address 1.22 婚姻状况 Marital status 已婚 Married 单身 Single

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1 Form V.2013 中华人民共和国签证申请表 Visa Application Form of the People s Republic of China (For the Mainland of China only) 申请人必须如实完整清楚地完整清楚地填写本表格请逐项在空白处用中文或英文大写字母打印填写, 或在内打选择如有关项目不适用, 请写无 The applicant should fill in this form truthful thfully ly,completely and clearly. Please type the answer in capital English letters in the space provided or tick ( ) the relevant box to select. If some of the items do not apply, please type N/A or None. 一个人信息 Part 1: Personal Information 姓 Last name 1.1 英文姓名 Full English name 中间名 Middle name as in passport 名 First name 1.2 中文姓名 in Chinese 1.4 性别 Sex 男 M 女 F 1.6 现有国籍 Current nationality ationality(ies) 1.8 出生地点 ( 市省 / 州国 ) Place of birth( irth(city ity, province/s /state tate,c,country ountry) 1.9 身份证 / 公民证号码 Local ID/ Citizenship number 护照 / 旅行证件种类 Passport/Travel document type 1.3 别名或曾用名 Other name ame(s) 1.5 出生日期 DOB OB(yyyy-mm-dd 1.7 曾有国籍 Former nationality ationality(ies) 外交 Diplomatic 普通 Ordinary 公务官员 Service or Official 粘贴一张近期正面免冠浅色背景的彩色护照照片照片 /Photo Affix one recent color passport photo (full face, front view, bareheadedand and against a plain light colored background). 其他证件 ( 请说明 ) Other (Please specify): 1.11 护照号码 Passport number 1.13 签发地点 Place of issue 1.15 当前职业 ( 可选多项 ) Current occupation(s) 商人 Businessperson 公司职员 Company employee 演艺人员 Entertainer 工人 / 农民 Industrial/Agricultural worker 学生 Student 乘务人员 Crew member 自雇 Self-employed 无业 Unemployed 退休 Retired 1.12 签发日期 Date of issue( ssue(yyyy-mm-dd 1.14 失效日期 Date of expir xpiry(yyyy-mm-dd 前 / 现任议员 Former/incumbent member of parliament 职位 Position 前 / 现任政府官员 Former/incumbent government official 职位 Position 军人 Military personnel 职位 Position 非政府组织人员 NGO staff 宗教人士 Religious personnel 新闻从业人员 Staff of media 其他 ( 请说明 ) Other (Please specify): 1.16 受教育程度 Education 研究生 Postgraduate 其他 ( 请说明 ) Other (Please specify): 大学 College 1.17 工作单位 / 学校 Employer/School 名称地址 Address 联系电话 Phone number 邮政编码 Zip Code 第 1 页共 4 页 / Page 1 of 4

2 1.18 家庭住址 Home address 1.19 邮政编码 Zip Code 1.20 电话 / 手机 Home/mobile phone number 1.21 电子邮箱 address 1.22 婚姻状况 Marital status 已婚 Married 单身 Single 其他 Other(Please specify): 1.23 主要家庭成员 ( 配偶子女父母等, 可另纸 ) Major family members(spouse, spouse, children,parents,et c.,may type on separate paper) 姓名国籍 Nationality 职业 Occupation 关系 Relationship 1.24 姓名紧急联络人信息 Emergency 与申请人的关系 Contact Relationship with the applicant 1.25 申请人申请签证时所在的国家或地区 Country or territory where the applicant is located when applying for this visa 手机 Mobile phone number 二旅行信息 Part 2: Travel Information 官方访问 Official Visit 旅游 Tourism 交流考察访问 Non-business visit 商业贸易 Business & Trade 人才引进 As introduced talent 执行乘务 As crew member 过境 Transit 短期探望中国公民或者具有中国永久居留资格的 2.1 申请入境事由外国人 Short-term visit to Chinese citizen or Major purpose foreigner with Chinese permanent residence status of your visit 短期探望因工作学习等事由在中国停留居留的外国人 Short-term visit to foreigner residing in China due to work, study or other reasons 短期学习 Short-term study for less than 180 days 短期采访报道 As journalist for temporary news coverage 其他 ( 请说明 )Other (Please specify): 常驻外交领事国际组织人员 As resident diplomat iplomat,consul onsul or staff of international al organization 永久居留 As permanent resident 工作 Work 寄养 As child in foster care 与中国公民或者具有中国永久居留资格的外国人家庭团聚居留超过 180 日 Family reunion for over 180 days with Chinese citizen or foreigner with Chinese permanent residence status 长期探望因工作学习等事由在中国居留的外国人 As accompanying family member of foreigner residing in China due to work, study or other reasons 长期学习 Long-term study for over 180 days 外国常驻中国新闻机构记者 As resident journalist 2.2 计划入境次数 Intended number of entries 一次 ( 自签发之日起 3 个月有效 ) One entry valid for 3 months from the date of issue 二次 ( 自签发之日起 3-6 个月有效 ) Two entries valid for 3 to 6 months from the date of issue 半年多次 ( 自签发之日起 6 个月有效 ) Multiple entries valid for 6 months from the date of issue 一年多次 ( 自签发之日起 1 年有效 ) Multiple entries valid for 1 year from the date of issue 其他 ( 请说明 )Other (Please specify): 2.3 是否申请加急服务 Are you applying for express service? 注 : 加急服务须经领事官员批准, 将加收费用 Note: Express service needs approval consular officials, and extra fees may apply. of 2.4 本次行程预计首次抵达中国的日期 Expected date of your first entry into China on this trip (yyyy-mm-dd 第 2 页共 4 页 / Page 2 of 4

3 2.5 预计行程中单次在华停留的最长天数 Longest intended stay in China among all entries Days 日期 Date 详细地址 Detailed address 2.6 在中国境内行程 ( 按时间顺序, 可附另纸填写 ) Itinerary in China (in time sequence,may type on separate paper) 2.7 谁将承担在中国期间的费用? Who will pay for your travel and expenses during your stay in China? 姓名或名称 2.8 中国境内邀请单位或个人信息 Information of inviter in China 地址 Address 联系电话 Phone number 与申请人关系 Relationship with the applicant 2.9 是否曾经获得过中国签证? 如有, 请说明最近一次获得中国签证的时间和地点 Have you ever been granted a Chinese visa? If applicable, please specify the date and place of the last time you were granted the visa 过去 12 个月中访问的其他国家或地区 Other countries or territories you visited in the last 12 months 三其他事项 Part 3: Other Information 3.1 是否曾在中国超过签证或居留许可允许的期限停留? Have you ever overstayed your visa or residence permit in China? 3.2 是否曾经被拒绝签发中国签证, 或被拒绝进入中国?Have you ever been refused a visa for China, or been refused entry into China? 3.3 是否在中国或其他国家有犯罪记录? Do you have any criminal record in China or any other country? 3.4 是否具有以下任一种情形 Are you experiencing any of the following conditions? 1 严重精神障碍 Serious mental dis isorder 2 传染性肺结核病 Infectious pulmonary tuberculosis 3 可能危害公共卫生的其他传染病 Other infectious disease of public health hazards 3.5 近 30 日内是否前往过流行性疾病传染的国家或地区?Did you visit countries or territories affected by infectious diseases in the last 30 days? 3.6 如果对 3.1 到 3.5 的任何一个问题选择是, 请在下面详细说明 If you select Yes to any questions from 3.1 to 3.5, please give details below. 第 3 页共 4 页 / Page 3 of 4

4 3.7 如果有本表未涉及而需专门陈述的其他与签证申请相关的事项, 请在此或另纸说明 If you have more information about your visa application other than the above to declare,please give details below or type on a separate paper. 3.8 如申请人护照中的偕行人与申请人一同旅行, 请将偕行人照片粘贴在下面并填写偕行人信息 If someone else travels and shares the same passport with the applicant, please affix their photos and give their information below. 偕行人信息 Information 偕行人 1 Person 1 粘贴照片于此 Affix Photo here 偕行人 2 Person 2 粘贴照片于此 Affix Photo here 偕行人 3 Person 3 粘贴照片于此 Affix Photo here 姓名 Full name 性别 Sex 生日 DOB OB( 四声明及签名 Part 4: Declaration & Signature 4.1 我声明, 我已阅读并理解此表所有内容要求, 并愿就所填报信息和申请材料的真实性承担一切法律后果 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 我理解, 能否获得签证获得何种签证入境次数以及有效期停留期等将由领事官员决定, 任何不实误导或填写不完整均可能导致签证申请被拒绝或被拒绝进入中国 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 我理解, 根据中国法律, 申请人即使持有中国签证仍有可能被拒绝入境 I understand that, according to Chinese law, applicant may be refused entry into China even if a visa is granted. 申请人签名 Applicant s signature: 日期 Date (yyyy-mm-dd : 注 : 未满 18 周岁的未成年人须由父母或监护人代签 Note: The parent or guardian shall sign on behalf of a minor under 18 years of age. 五他人代填申请表时填写以下内容 Part 5:If the application form is completed by another person on the applicant's behalf, please fill out the information of the one who completes the form 5.2 与申请人关系 Relationship 5.1 姓名 with the applicant 5.3 地址 Address 5.4 电话 Phone number 5.5 声明 Declaration 我声明本人是根据申请人要求而协助填表, 证明申请人理解并确认表中所填写内容准确无误 I declare that I have assisted in the completion of this form at the request of the applicant and that the applicant understands and agrees that the information provided is true and correct. 代填人签名 /Signature: 日期 /Date (yyyy-mm-dd : 第 4 页共 4 页 / Page 4 of 4

5 CONSENT FOR PROCESSING PERSONAL DATA AND BIOMETRIC DATA 处理个人信息及生物信息同意函 PLACE 地址 DATE 日期 I, the undersigned, citizen of hereby give my express consent to the collection, use and processing of any personal data (data that can be used to directly or indirectly identify someone) by CITS V Service Netherlands B.V. (CITS) and consequently the Chinese embassy in the Netherlands for my Chinese visa application. 本人, 即签署人, 公民特此明示同意中国国旅荷兰签证公司 (CITS) 及后续中国驻荷兰大使馆出于中国签证申请流程之目的而收集使用和处理个人信息 ( 可以用来直接或间接识别自然人身份的信息 ) 1. This collection, use and processing of my personal data is necessary to process and complete my Chinese visa application. CITS and the Chinese embassy in the Netherlands will collect and process applicants personal data as provided by me the applicant. 所收集使用和处理的个人信息为处理并完成本人中国签证申请流程的必要信息 CITS 及中国驻荷兰大使馆将收集并处理本人, 即签证申请人, 所提供的个人信息 2. This personal data may include the following information: my surname, name, gender, place of birth, age, address, phone, address, family status, social status, marital status, education, profession, income and data characterizing my physiological particularities, including but not limiting to, photo, video, fingerprints of all fingers of both hands (biometric data). 该个人信息可能包括以下信息 : 本人的姓氏名字性别出生地年龄地址电话号码邮箱地址家庭状况社会地位婚姻状况教育背景职业收入以及能够突出显示生理特点的信息, 包括但不限于, 照片视频双手所有手指的指纹 ( 生物信息 ) 3. The People s Republic of China is committed to securing its homeland safety while offering you legitimate travel. The use of biometric data assists the officers working for the competent authorities which review and issue the Chinese visa in verifying your identity. Biometric data is collected abroad in the Netherlands (at the CITS offices or the Chinese embassy in the Netherlands) and checked at ports of entry in the People s Republic of China as well to verify that the person travelling with the visa is the same person to whom the visa was issued. If you refuse to have your fingerprints taken, your visa application will be refused as it will be considered incomplete. 中华人民共和国致力于在为您提供合法签证的同时确保本国国家安全中国签证官员将通过生物信息对您进行身份验证生物信息将在荷兰境内收集 ( 在 CITS 办公室或中国驻荷兰大

6 使馆处 ) 此外, 并在中华人民共和国入境口岸进行身份验证以确保持签证旅行者与签证持有人为同一人如果您拒绝提供指纹, 您的签证申请将因申请材料不全而被拒绝 4. On your visa interview day, CITS will scan your ten fingers and immediately transmit this biometric data to the Chinese embassy in the Netherlands. CITS does not store any personal data, including biometric data. If for some reason your biometric data cannot be collected (e.g. your hand/fingers are missing or your fingerprints have been eroded), CITS will discuss this matter with you. The fingerprints of children under 16 years old will not be collected. CITS 将会在签证面谈日扫描您的十指指纹并即刻将该生物信息传送至中国驻荷兰大使馆 CITS 并不存储包括生物信息在内的个人信息如出于某种原因 CITS 无法收集您的生物信息 ( 例如, 您的手 / 手指缺失或是您的指纹曾被侵蚀 ),CITS 会与您进行沟通 CITS 不收集十六岁以下儿童的指纹 5. CITS and the Chinese embassy located in the Netherlands will collect and process the applicants personal data only for the purpose of processing the applicants Chinese visa application. Except for competent authorities that need to review and issue the Chinese visa, CITS and the Chinese embassy located in the Netherlands will not disclose personal data to other third parties. CITS 以及中国驻荷兰大使馆仅出于处理申请人的中国签证申请之目的收集并处理申请人的个人信息除需要审核签发中国签证的主管部门外,CITS 以及中国驻荷兰大使馆不会向其他第三方披露个人信息 6. When CITS and the Chinese embassy located in the Netherlands collect, transmit and store personal data, CITS and the Chinese embassy located in the Netherlands will strictly comply with relevant laws and regulations, including data protection laws. CITS 以及中国驻荷兰大使馆的个人信息收集传送及存储行为会严格遵守包括数据保护法在内的相关法律法规 7. I, therefore, consent that my personal data and biometric data that is needed or recommended to obtain a Chinese visa can be, amongst others, gathered, systematized, accumulated, stored, amended, used, distributed, depersonalized, blocked, deleted, as well as any other actions following the acting legislation of the People s Republic of China. 本人, 因此, 同意对获取中国签证所必须或建议提供的包括个人信息和生物信息在内的信息, 进行收集系统化累积存储更正使用分布去人格化封锁删除或者进行其他依中华人民共和国现行法律所需进行的行为 8. I also consent and confirm that CITS and the Chinese embassy in the Netherlands may disclose this data to third parties and that this data may be transferred outside the European Economic Area if this is required for the visa application process. 本人同意并确认, 出于签证申请流程之目的,CITS 以及中国驻荷兰大使馆可向第三方披露该个人信息且该信息可被传输出欧洲经济区境外

7 I hereby acknowledge that I have completely read, fully understood and agreed to the above terms of this document. 本人在此确认已完整阅读, 充分理解并同意本文上述所列条款 Applicant s signature 申请人签名 : Date 日期 : Signature 签名 : Date 日期 : (Another person on the applicant s behalf) ( 申请人的代理人 )

Form V.2013 中华人民共和国签证申请表 Visa Application Form of the People s Republic of China (For the Mainland of China only) 申请人必须如实完整清楚地完整清楚地填写本表格请逐项在空白处用中文

Form V.2013 中华人民共和国签证申请表 Visa Application Form of the People s Republic of China (For the Mainland of China only) 申请人必须如实完整清楚地完整清楚地填写本表格请逐项在空白处用中文 Chinese Visa Application Your Chinese visa application must be typed or filled out on the attached fillable PDF, printed, and signed. Handwritten applications are not accepted. Please completely fill in