样张

英国签证申请人结核筛查体检登记表 Registration Form of TB screening Physical Examination for UK Visa Applicant

姓Family name 名Given name 性别Gender

出生日期Date of birth 日/月/年 国籍Nationality

11岁以下儿童(不含11岁)的人数Number of accompanying children under 11 years of age

护照号码Passport No. 护照有效期Passport expiry date 日/月/年 签证类型Visa Category

电话Phone

中国居住地址全称(中英文) Full residential address

英国地址(英文) Address in the UK

英国地址邮政编码 Post code in the UK

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王 WANG 小明 XIAOMING

男25/05/1995中国0G1111111125/05/2015T413761111111上海市长宁区金浜路15号3号楼201室Room 201, Building 3, No.15 Jinbang Road, Changning District, Shanghai, China University of Southampton ，University Road ， Southampton ，Hampshire ， UK S017 IBJ 样 张

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