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Appendix Declaration of Intent To Undergo A TB Test: Surname As Stated in The Border-Crossing Document

The document is a declaration of intent for a foreign national to undergo tuberculosis (TB) testing in order to obtain a residence permit in the Netherlands. It states that the individual must be willing to undergo TB testing and treatment if necessary. It also notes that if the individual does not get tested within 3 months of permit approval, the permit could be cancelled. The declaration must be completed and signed to confirm the individual's agreement to cooperate with TB testing requirements.

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Sheikh Nasiruddin
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132 views

Appendix Declaration of Intent To Undergo A TB Test: Surname As Stated in The Border-Crossing Document

The document is a declaration of intent for a foreign national to undergo tuberculosis (TB) testing in order to obtain a residence permit in the Netherlands. It states that the individual must be willing to undergo TB testing and treatment if necessary. It also notes that if the individual does not get tested within 3 months of permit approval, the permit could be cancelled. The declaration must be completed and signed to confirm the individual's agreement to cooperate with TB testing requirements.

Uploaded by

Sheikh Nasiruddin
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Appendix Declaration of intent to undergo a TB test

In order to obtain a residence permit, you (or the person you represent) must be prepared to undergo a
tuberculosis (TB) test and - if necessary - treatment. If you submit the completed declaration of intent to
undergo a TB test to the IND together with your application (and also meet all other conditions), the IND will
grant you a residence permit as soon as possible.

You are granted this permit under the express condition that you will actually undergo a TB test within three
months. Should it become clear after the issue of a residence permit that - despite signing the declaration of
intent - you failed to undergo a TB test within the period of three months, this may result in a cancellation of
the permit that was granted.

Enclose the completed and signed declaration of intent with your application before you make an appointment
with the Municipal Health Service. In doing so, you declare that you are prepared to undergo a TB test and, if
necessary, TB treatment. For the appointment with the Municipal Health Service, you must complete the
referral form as much as possible (part 1) and take it with you.

The obligation to undergo the test does not apply if you are a national of one of the following countries: one of
the Member States of the EU or the EEA, Australia, Canada, Israel, Japan, Monaco, New Zealand, Suriname,
United States of America and Switzerland (including Liechtenstein). Nor does the obligation to undergo the test
apply if you have an EU residence permit for long-term residents issued by another EU country or are his/her
family member and were already admitted to another EU country as a family member of the long-term
resident.

1 Details of foreign national to be tested (the applicant)


1.1 Application for a permit for the purpose of work, wealthy foreign national, □ Yes □ No
learning while working or study?
1.2 V-number (if known)
1.3 Name Surname as stated in the border-crossing document

First names

1.4 Sex and Date of birth > Please tick the applicable situation Day Month Year
□ Male □ Female
1.5 Place of birth

1.6 Country of birth


1.7 Nationality

1.8 Home address Street Number

Postcode Town

1.9 Civil status > Please tick the applicable situation


□ unmarried □ married □ registered partnership □ divorced
□ widow/widower
1.10 Details border-crossing Number Country
document (passport)
Valid from (date) Valid until (date)

1.11.1 Do you have a spouse or (registered) partner?


□ No > Go to 2 'Signing'
□ Spouse > Please complete the requested details below
□ (Registered) partner > Please complete the requested details below
1.11.2 Name Surname as stated in the border-crossing document

First names

1.11.3 Sex > Please tick the applicable situation


□ Male □ Female
1.11.4 Nationality
1.11.5 Home address Street Number

Postcode Town
2 Signing
I hereby declare that I am prepared to cooperate in a tuberculosis test and any treatment. I am aware of the
fact that I must undergo a TB test within three months after the application for a residence permit has been
submitted. If I fail to do so, this will have consequences for my right of residence in the Netherlands.

2.1 Name of foreign national

Place Day Month Year


2.2 Place and date

2.3 Signature of foreign national

2.4 Name in case of legal


representative

Place Day Month Year


2.5 Place and date

2.6 Signature of legal


representative

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