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Form V.2011A

Visa Application Form of the Peoples Republic of China

Applicant should fill out this form truthfully and completely on a computer and print out. Please type your answer in capital English letters in the space provided or cross the appropriate box to select. Please state N/A or None if a section does not apply to you. If there is additional information to declare, please type on a separate sheet. (Form V.2011B) Please also complete the Supplementary Visa Application Form (Form V.2011B) if you are not a U.S. citizen, or if you are applying for work visa or student visa, or if you will be accompanied by anyone who shares the same passport with you.
Section 1Personal information Surname 1.1 Full name as shown on your passport Given name 1.2 Sex

M F

Replace with your first & middle name as in passport

None
None
As in 1.1
1.7 Former nationality

Photo requirements
1 One colored photo 6 Within 6 months Passport photo Front-facing Hatless Light-colored background

1.3 Name in Chinese character ( if applicable) 1.4 Other name or previous name if applicable 1.5 Name in native language 1.6 Current nationality 1.8 Concurrent nationality 1.10 (/) Place of birth (city, province/state, country) 1.12 Marital status

None

1.9 Date of birth (yyyy-mm-dd) 1.11 U.S. ID card number

Married Widowed
Businessman

Never Married Divorced OtherPlease specify:

Government official Staff of media Religious worker Active duty military personnel Member of national parliament Crew member

Company employee Teacher Student Housewife Unemployed

1.13 Current occupation(s)

Retired () Other (Please specify):

1.14 Passport type 1.15 Passport number 1.17 (/) Place of issue (city, province/state, country) 1.19 () Please select pick-up day (Extra fee is charged for express pick-up) .

Diplomatic passport / Service/Official passport Ordinary passport ()Other (Please specify):

1.16 Date of issue (yyyy-mm-dd) 1.18 Expiry date (yyyy-mm-dd) .

( 4-5 ) Normal (the 4th or 5th working day) ( 2-3 )Express (the 2nd or 3rd working day)
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Form V.2011A

Section 2: Details of travel to China

Tourism Family visit

2.1 Major purpose(s) of your visit(s) to China

As resident journalist As journalist for temporary news coverage As resident diplomat or consul Commercial performance As crew member Study Official visit
. One entry valid for 3 months from date of application Two entries valid for 6 months from date of application

Visiting friends Business trip Meeting Transit Employment () Other (Please specify): ( 3 )

2.2 Intended number of entries

( 6 )

6 Multiple entries valid for 6 months from date of application 12 Multiple entries valid for 12 months from date of application Other (Please specify):
.

2.3 Intended date of your first entry (yyyy-mm-dd) 2.4 Your longest intended duration of stay 2.5 i) Please list cities and provinces to visit in China in a time sequence 2.5 ii) Please list residence(s) and phone number(s) during your stay in China in a time sequence Detailed address 1. 2. 3. 4. 2.6 Who will pay for your trip to China? City Province Phone number Days

Replace with detail address here. Must list detail street address, not only hotel name!

Myself Inviter Parent(s) or guardian(s) Other (Please specify): Yes No

2.7 ?Do you have medical insurance covering your visit in China? If Yes, please fill out the name of the medical insurance company and your account number. 2.8 / Name, address and phone number of your inviter or contact unit in China 2.9 / Name, address and phone number of your relative, friend or contact person in China 2011 6 CNNYCONSULATE JUNE 2011 EDITION

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Form V.2011A

Section 3: Information about your family, work or study 3.1 Address Current home address 3.2 Home phone number 3.4 Email address 3.5 Name, phone number and address of your current employer or school Name Address City Name / Province/State

City

/ Province/State

Zip code

3.3 Mobile phone number

Phone number Zip code Occupation

Nationality

Relationship

3.6 Major family members

3.7 Contact person in case of emergency Section 4: Other information 4.1 Have you ever visited China before? If Yes, please specify date, places and purpose of the latest visit. 4.2 12 Have you ever visited other countries or territories in the past 12 months? If yes, please specify date, name of countries or territories and purpose of the visits. 4.3 Have you ever overstayed your visa or residence permit in China? 4.4 , Have you ever been refused a visa for China, or been refused entry into China? 4.5 Do you have any criminal record in China or any other country? 4.6 ? Are you suffering from any of the following diseases? Serious mental disorder Infectious pulmonary tuberculosis Other infectious disease of public health hazards 4.7 30 Did you visit countries or territories infected by infectious diseases in the past 30 days?

3.8 Contact persons phone number

No Yes No Yes

Yes Yes Yes

No No No

Yes

No

Yes

No

2011 6 CNNYCONSULATE JUNE 2011 EDITION

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Form V.2011A

4.8 4.3 4.7 If you answered Yes to any of questions 4.3 to 4.7, please give details below.

N/A

Section 5: Relevant declaration 5.1 (Form V.2011B)Please also complete the Supplementary Visa Application Form (Form V.2011B) if you are not a U.S. citizen, or if you are applying for work visa or student visa, or if you will be accompanied by anyone who shares the same passport with you. 5.2 Please use the space below or a separate sheet for additional information / declaration / statement other than already provided in this application.

None

Section 6: Signature 6.1 I have read and understood all the questions in this application. I declare that the information provided above is true and accurate. I shall take all responsibilities for any false information. 6.2 I understand that the decision on whether to issue a visa, validity/ type of visa, number of entries, and duration of each stay will be decided by consular officers, and that any false, misleading or incomplete information may result in the refusal of a visa or denial of entry into China. Date (yyyy-mm-dd): . Applicants signature: 18 Note: Parent or guardian may sign on behalf of an applicant aged under 18. Section 7If the application form is completed by another person on the applicants behalf, please fill out the following: 7.1 7.2 Name of the person completing Relationship to the this form on the applicants behalf applicant 7.3 Address 7.4 Phone number

7.5 7.6 Type of ID document Number of ID 7.7 Declaration I declare that I have assisted in the completion of this form at the request of the applicant, and the applicant understands and confirms that the information provided is true and correct.

/Signature Official use only

/Date (yyyy-mm-dd):

2011 6 CNNYCONSULATE JUNE 2011 EDITION

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