姓（如護照所示）SURNAME

 (As in Passport)

名（如護照所示）FIRST AND MIDDLE NAMES (As in Passport)

照片PHOTO

別名或曾用名

（英文）OTHER NAME USED

中文姓名 CHINESE NAME

性別 GENDER

出生日期DATE OF BIRTH(yyyy-mm-dd)

國籍NATIONALITY

變更項CHANGED OBJECTS

變更前

 BEFORE CHANGE

變更后

AFTER CHANGE

用人單位承諾如實向行政機關提交有關材料和反映真實情況，并對申請材料實質內容的真實性負責，并承擔相關法律責任，同意許可決定機構根據需要進行補充調查。

Reference revision: The employer hereby declares that all the documents and information submitted to the authority are true, and shall be responsible for the authenticity of the documents and undertake corresponding legal responsibilities. The employer should give the consent to the authority’s supplementary investigation as necessary.

用人單位公章（Seal of Employer）

年    月    日

YYYY     MM   DD

   申請人簽名：

   SIGNATURE OF APPLICANT

年    月    日

YYYY     MM   DD