For Issuance/ Extension of Residence Card and Registration of Residence for Third Country

DATA SHEET

FOR ISSUANCE/ EXTENSION OF RESIDENCE CARD AND REGISTRATION OF RESIDENCE FOR THIRD COUNTRY NATIONAL FAMILY MEMBER OF EEA CITIZEN

Date of requesting the Issuance/ Extension of Document: / File Number: ׀_׀_׀_׀_׀_׀_׀_׀_׀_׀_׀
______Year ______Month ____ Day
Purpose of Application:
□Issuance of Document.
□Extension of Document.
Place of Receipt of Document
Applicant will receive the document at the issuing authority.
Applicant will receive the document by postal mail
E-mail:
Phone: / Photo
[Signature Specimen of Applicant (Legal Representative)]
Please make sure the signature fits in the box.
I. Personal Data of Holder of the Right of Residence
Name of Applicant
1. Family Name:
2. Given Name(s):
Previous Name(s) or Given Name(s) at Birth
3. Family name:
4. Given Name(s) at Birth:
Mother's Family and Given Name(s) at Birth:
5. Family name:
6. Given Name(s) at Birth:
Place of Birth
7. Country:
8. City/Town:
9. Date of Birth: / Year MonthDay
10. Gender: / Male: / Female:
11. Citizenship:
12. Marital Status: / single / married / widowed divorced
II. Applicant's Passport Data
21. Passport Number:
22. Type of Passport: / ordinary / service / diplomatic
other:
Place of Issue
23. Country:
24. City/Town:
25. Date of Issue: / Year Month Day
26. Date of Expiration: / Year Month Day
III. Date related to Current Residence Card (in case of extension)
31. Number of Document:
32. Date of Issue: / Year Month Day
33 Date of Expiration:Year Month Day
IV. Data of Applicant's Residence in Hungary
41. ZIP code:
42. City/Town: / District:
43. Name of Public Premises:
44. Type of Public Premises (road, street, etc.):
45. House Number orLot Number:
Building: / Staircase: / Floor: / Door:
46. Legal basis for reporting residence in Hungary:
I hereby declare and affirm that I am the owner of the property specified above.
I hereby enclose the consent statement of the owner of / the person legally entitled to use the above specified property.
V. Data of EEA Citizen (accompanied by the Applicant)
51. Family Name:
52. Given Name(s):
Place of Birth
53. Country:
54. City/Town:
55. Date of Birth / Year Month Day
56. Gender: / Male: / Female:
57. Citizenship:
58. Relationship: / Parent
Child
Spouse / Life Partner, in case this relationship is registered with Hungarian or another EU Member State authorities / Other (please specify): / Dependent of EEA citizen
lives in common household with EEA citizen for at least 1 year
personally cared for by EEA citizen due to serious health issues
VI. Other Data
61. Are you aware of any disease or medical condition (such as HIV/ AIDS, tuberculosis, Hepatitis B, syphilis, leprosy, typhus or other that need permanent medical treatment) you have? Do you carry any of the following contagious diseases: HIV, Hepatitis B, typhus or paratyphus?
Yes / No
62. If you are suffering from or carrying any of the above specified contagious diseases or medical conditions, do you receive an obligatory and regular medical treatment? Yes No
63. Permanent or Habitual Residence (prior to arrival in Hungary):
Country:
City/Town:
Name of Public Premises:
64. Which country do you intend to return to or travel onward to on abandoning your right to reside or after the expiration of your legal residence?
Country:
I certify that the data and answers I have furnished on this form are true and correct to the best of my knowledge and belief.
Date: ______/ ______
Signature of Applicant
DO NOT WRITE IN THIS SPACE.
THIS SPACE IS TO BE FILLED OUT BY THE ACTING AUTHORITY.
I hereby give approval to the issuance / extension of Residence Card valid until
______Year ______Month ______Day for the Applicant.
Date: ______/ ______
(Signature of Officer, Seal)
Number of Document Issued: / ______
I hereby acknowledge the receipt of the above residence card.
Date: ______/ ______
(Signature of Applicant) / (Signature of Applicant)
In case of extension, the number of previous residence card: ______
Stamp Duty:
In case the application is denied
Number of Denial Decision: ______
Date of Denial: ______Year ______Month ______Day
Reasons for Denial (in brief):
In case the application procedure is terminated
Number of Termination Decision: ______
Date of Decision: ______Year ______Month ______Day
Reasons for Termination (in brief):