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Application For Certificate of Entry and Exit Dates: ( ( ( (Purpose(s) For Applying) ) ) )

This document is an application for a Certificate of Entry and Exit Dates from Taiwan for Tien-Lin Hsieh. It provides personal details for Mr. Hsieh such as name, date of birth, nationality, and ID number. It also lists the period of inquiry as dates of last entry and exit from Taiwan from 1989 to the date prior to this application. Contact information is also provided for the authorized agent assisting with the application, Pei-Yen Hsieh. The applicant declares that all information and documents provided are true and requests the certificate to support a United States visa application.

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Tien-LinHsieh
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120 views1 page

Application For Certificate of Entry and Exit Dates: ( ( ( (Purpose(s) For Applying) ) ) )

This document is an application for a Certificate of Entry and Exit Dates from Taiwan for Tien-Lin Hsieh. It provides personal details for Mr. Hsieh such as name, date of birth, nationality, and ID number. It also lists the period of inquiry as dates of last entry and exit from Taiwan from 1989 to the date prior to this application. Contact information is also provided for the authorized agent assisting with the application, Pei-Yen Hsieh. The applicant declares that all information and documents provided are true and requests the certificate to support a United States visa application.

Uploaded by

Tien-LinHsieh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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(Y) (M) (D)

APPLICATION FOR CERTIFICATE OF ENTRY AND EXIT DATES

Applicant Name Sex Date of Birth Nationality I.D. or Passport No. Tel. No.
1 x M 1989 7 15 Taiwan F 1 2 6 9 6 7 4 8 0 0227620557
Tien-Lin Hsieh 謝天林林
F Y M D

(Select the Period of Inquiry)


2 Dates of Last Entry and Exit
x From 1989 Y To The Day Prior To Application Date

3 Authorized Agent Sex Date of Birth Nationality I.D. or Passport No. Tel. No.
(Read

x M 1957 12 08 Taiwan F 1 2 0 60 6 9 1 5
Pei-Yen Hsieh 謝培岩 F Y M D
0227620557

裝
4 Concerned Parties Sex Date of Birth Nationality I.D. or Passport No. Tel. No.
M
Notice

F Y M D

Type of Documents Attached


Litigation Tax Household Registration
Military Health Insurance
Other
Before

(Purpose(s) for Applying))


I hereby declare the foregoing statements and attached documents are true
United States Visa application and accurate. If any information provided above is False or incorrect, I will
Fill

assume all legal responsibility.


5
in)

Signature of Applicant or Agent

(Notice)
(False statement will be subject to the penalties per Criminal Codes)
線
A4
*
Please submit the original I.D. Card, Passport, Power of Attorney and relevant documents, and one copy of
each in A4 paper
________ 1 2 5 Apply in person ; complete sections 1, 2, 5
________ 1 2 3 5 Apply by agent; complete sections 1, 2, 3, 5
____ 1 2 4 5 Concerned parties; complete sections 1, 2, 4, 5
A4

( Approval ) ( For Official Use Only

*
(
Fax:_________________( )

103.10.150 ( )

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