Authorization form

I,
First name :
_________________________________________________________________________________
Family name :
_________________________________________________________________________________
Date of birth :
_________________________________________________________________________________
Nationality :
_________________________________________________________________________________
V number :
_________________________________________________________________________________
Student number :
_________________________________________________________________________________
Email address :
_________________________________________________________________________________
Phone number :
_________________________________________________________________________________
I am currently a 1st / 2nd / 3rd / 4th / higher year / master / prep student (please encircle)

Hereby give my power of attorney to The Hague University of Applied Sciences to take
the necessary actions regarding the extension of my residence permit with the restriction
of studying

Grant permission to the institution to notify the IND in the event that I am no longer studying
or
graduated at this institute.

Want to (re-)enrol for the academic year 2010-2011 in the programme:

___________________________

Have at least € 9.600,- at my disposal to cover all necessary costs for living and
studying in the Netherlands for the academic year 2010-2011.

I have a healthcare insurance policy for the academic year 2010-2011.

* Please check and tick ALL boxes

I have truthfully completed all sections of this application and certify that all the
information I have supplied is correct. I understand that if I have supplied incorrect or
misleading information, or have omitted any important information that this may result in
the application being refused and also that The Hague University of Applied Sciences
cannot accept any liability for such a refusal.

Place : ____________________________________________

Date : ____________________________________________

Signature :
You can only use this form if you continue with the same programme, start with a new
Bachelor programme at this institute or if you will start with a master programme at this
institute, that is in the line with your Bachelor degree you have received at this institute.

Together with this form, please hand in the following documents:

- a copy of your current residence permit, both sides
- proof of payment legal fees (a print out of the bank transfer, or a copy of your bank
statement) NFP students should not pay the fees
- copy of your current student card For office use only
Datum leges ontvangen :
_______________________

Bankafschrift nummer :
________________________