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.
1
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
No
n
n
learning while working or study?
1.2
How did you come to the
Netherlands?
With
Without
a valid regular provisional residence permit
n
n
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
n
n
1.6
Place of birth
|
1.7
Country of birth
|
1.8
Nationality
|
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