Tb Test Referral Form printable pdf download

Appendix

TB test referral form

In order to obtain a residence permit, you (or the person you represent)

Please complete the referral form before you make an appointment

must be prepared to undergo a tuberculosis (TB) test and - if necessary -

with the Municipal Health Service. See also for information

treatment. If you submit the completed declaration of intent to undergo

about the Municipal Health Service. The completed form signed by the

a TB test to the IND together with your application (and also meet all

Municipal Health Service, showing that you underwent a TB test, must

other conditions), the IND will grant you a residence permit as soon as

have been received by the IND from the Municipal Health Service within

possible.

three months after the date on which the application for a residence

permit has been submitted.

You are granted this permit under the express condition that you will

actually undergo a TB test within three months. Should it become clear

The obligation to undergo the test does not apply if you are a national

after the issue of a residence permit that - despite signing the declaration

of one of the countries listed in the appendix ‘Exemption from the

of intent - you failed to undergo a TB test within the period of three

obligation to undergo a tuberculosis (TB) test’. Nor does the obligation

months, this may result in a cancellation of the permit that was granted.

to undergo the test apply if you have an EC residence permit for

long-term residents issued by another EU country or are his/her family

In order to undergo the TB test, you must make an appointment with the

member and were already admitted to another EU country as a family

Municipal Health Service. For this appointment, you must complete the

member of the long-term resident.

referral form as much as possible (part 1) and take it with you.

Details of foreign national to be tested (the applicant)

The State Secretary for Security and Justice asks the director of the Municipal Health Service to test the below-

mentioned person for tuberculosis (in the respiratory organs), as referred to in the Aliens Act Implementation

Guidelines.

The foreign national (the applicant) completes this section (part 1)

1.1

Application for a permit for the purpose

of work, wealthy foreign national,

Yes

learning while working or study?

1.2

How did you come to the

Netherlands?

With

Without

a valid regular provisional residence permit

1.3

V-number (if known)

Surname as stated in the passport

1.4

Name

First names

> Please tick the applicable situation

Day

Month

Year

1.5

Sex and Date of birth

Male

Female

1.6

Place of birth

1.7

Country of birth

1.8

Nationality

b04

Tb Test Referral Form

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