Please read through the text in this form carefully. If
you agree with the options under ‘I certify that’ you
can check the first box.
Antecedents Certificate
If younational
cannotisdeclare
This certificate only needs to be completed if the foreign
12 yearsthe
of statements,
age or older. please explain
the reason in a separate e-mail to:
immigration@tilburguniversity.edu
1 Certificate
> Please tick the applicable situation
□ I certify that:

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
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





I have never been sentenced to imprisonment or a custodial measure for committing a crime;
I have never been sentenced to perform community service for committing a crime;
I have never been imposed an unconditional fine for committing a crime;
I have never accepted an out-of-court settlement for committing a crime;
I have never been imposed a penalty order by a public prosecutor for committing a crime;
I am currently not subject to prosecution for committing a crime;
I have never been responsible for one of the following categories of acts as referred to in
Article 1F of the 1951 Refugee Convention: a crime against peace, a war crime, a crime
against humanity, a serious non-political crime (for example murder or terrorism), or acts
contrary to the purposes and principles of the United Nations (for example terrorist acts); and
I am aware of the fact that a sentence for committing a crime may result in a refusal or
termination of the right of residence.
I have not submitted any incorrect data during earlier residence procedures;
I did not reside in the Netherlands illegally in the past;
I am not subject to any entry ban.
□ I am unable to certify the above for the following reasons:
Please write down your name as
stated in your passport, current
place, date and signature.
2 Signing
I have completed this form truthfully.
2.1 Name
2.2 Place and date
Place
Day Month Year
2.3 Signature
Please note!
If this antecedents certificate has not been completed truthfully, this will have consequences for your
right of residence.
Please complete if you are a
degree-seeking student.
If you are an exchange student you
do not need
to complete this page.
AUTHORIZATION FORM FOR THE STUDY PROGRESS
MONITORING
(degree-seeking students)
I, the undersigned,
Please complete in CAPITAL letters!
Last name (as stated in
passport)
First name (as stated in passport)
Date of Birth (dd-mm-yyyy)
Nationality
hereby give my permission for the Immigration Office at Tilburg University to share information
regarding my study progress with the Academic Advisor at my School, the Dean of Students and
the Dutch Immigration Service while I am registered as a student at Tilburg University.
50% REQUIREMENT
I am aware that I need to obtain at least 50% of the nominal number of ECTS per academic year
or part of it in case I have started my studies at a later date than 1 September. *
I am aware that if I encounter problems that keep me from meeting the 50% requirement, I must
inform my Academic Advisor or Program Coordinator and the Dean of Students at the time the
problems occur. Only students with a valid reason will not be reported to the IND.
The following reasons can possibly prevent my residence permit from being revoked:
 serious illness;
 exceptional family circumstances;
 pregnancy;
 physical, sensorial or other functional disturbance;
 membership or position on a university board;
 insufficiently feasible study program.
TIMEFRAME
I am aware that study progress will be monitored every academic year. The credits obtained
between September 1 and Augustus 31 of the following year will be taken into account for that
specific academic year. After each academic year, Tilburg University will determine my annual
study progress.
CONSEQUENCES
I am aware that if I do not have sufficient study progress at the end of one academic year and I
do not have a valid reason approved by the Dean of Students, the Immigration Office of Tilburg
University needs to report this to the Dutch Immigration Service (IND). The IND will then revoke
my residence permit for study purposes. I am aware that as a consequence, I will have to
withdraw from my study program at Tilburg University and I will either have to change the
purpose of my stay or leave the Netherlands.
Place
Date (dd-mm-yyyy)
:
:
Don’t forget to sign the form.
Signature
: …………………………………………………………………………………
(as stated in passport)
* More information can be found in the relevant immigration guide or on the TiU website:
http://www.tilburguniversity.edu/education/immigration/noneu/currentstudent/
Please check whether you need to fill out this appendix.
Please COMPLETE if your country of nationality is NOT mentioned in the appendix ‘Exemption from
the obligation to undergo a tuberculosis (TB) test’.
Do NOT complete if you already hold a Dutch residence permit.
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 countries listed in the
appendix ‘Exemption from the obligation to undergo a tuberculosis (TB) test’. 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)
Tick ‘yes’
1.1 Application for a permit for the purpose of work, wealthy foreign national,
learning while working or study?
Leave this blank.
1.2 V-number (if known)
1.3 Name
Surname as stated in the border-crossing document
□
□
Yes
No
First names
1.4 Sex and Date of birth
> Please tick the applicable
situation
□ Male
□ Female
Day Month Year
Complete
1.3 – 1.10
1.5 Place of birth
as requested.
1.6 Country of birth
1.7 Nationality
1.8 Home address
1.9 Civil status
Street
Number
Postcode
Town
> Please tick the applicable situation
□ unmarried □ married □ registered partnership □ divorced
□ widow/widower
1.10 Details border-
Number
Country
crossing document
If you have a spouse or (registered) partner that
will be traveling with you and that will be living in
the Netherlands, please tick the relevant box and
fill out the personal data.
Valid from (date)
Valid until (date)
In all other cases tick ‘no’!
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
1.11.3 Sex
1.11.4 Home address
Surname as stated in the border-crossing document
Only complete
if you have a
spouse or
First names
(registered)
partner that will
be traveling
> Please tick the applicable situation
with you and
□ Male
□ Female
that will be
Street
Number
living in the
Netherlands.
Postcode
Town
1.11.5 Nationality
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
2.2 Place and date
Complete
Day Month Year 2.1 – 2.3
as
requested
2.3 Signature of foreign
national
2.4 Name in case of legal
representative
2.5 Place and date
2.6 Signature of legal
representative
Place
Day Month Year
Leave
2.4 – 2.6
blank
Exemption from the obligation to undergo a tuberculosis (TB) test
Do not enclose this appendix with the form!
If you have the nationality of one of the countries on this list, you do not have to undergo a tuberculosis (TB)
test.
Albania
Andorra
Antigua and Barbuda
Argentina
Australia
Austria
Bahamas
Bahrain
Barbados
Belgium
Belize
Bosnia and Herzegovina
Brazil
Bulgaria
Canada
Chile
Colombia
Comoros
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dominica
Egypt
El Salvador
Estonia
Fiji
Finland
France
Germany
Greece
Grenada
Hungary
Iceland
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jemen
Jordan
Kuwait
Latvia
Lebanon
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Maldives
Malta
Mauritius
Mexico
Monaco
Montenegro
Netherlands
New Zealand
Nicaragua
Niue
Norway
Oman
Panama
Paraguay
Poland
Portugal
Qatar
Romania
Samoa
San Marino
Saudi Arabia
Serbia
Seychelles
Singapore
Slovakia
Slovenia
Spain
St Kitts & Nevis
St Lucia
St Vincent and the Grenadines
Suriname
Sweden
Switzerland
Syria
Tonga
Trinidad and Tobago
Tunisia
Turkey
United Arab Emirates
United Kingdom
United States of America
Uruguay
Venezuela
Please check whether you need to fill out the embassy form
Please complete if you will travel to the Netherlands with a visa!
Do NOT complete if your nationality is one of the following:
Australia, Canada, Japan, Monaco, New Zealand, South Korea, United States of America, Vatican City
Do NOT complete if you already hold a Dutch residence permit.
Embassy form
Once my application has been approved by the IND, I want to apply for my Dutch entry visa
(MVV) at the Dutch diplomatic post in:
1. Place
Fill in the place and
country of the Dutch
embassy / consulate
2. Country
In case you want to apply for your MVV at a Dutch diplomatic post in a country of which you are
not a national (i.e. your country of legal residence) please note that you require a residence
permit of that country with a validity of at least 4 months as of the moment you apply for your
MVV at the Dutch diplomatic post.
For your information: only Embassies and Consulate-Generals are allowed to issue entry
visas for long stay purposes (MVVs). A list of all Dutch diplomatic posts can be found on
the following website: https://www.government.nl/topics/embassies-consulates-and-otherrepresentations/contents