(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 ( )