> Please tick the applicable situation

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1 Antecedents Certificate I certify that: 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. This certificate only needs to be completed if the foreign If you national cannot is declare 12 years the of statements, age or older. please explain the reason in a separate to: 1 Certificate immigration@tilburguniversity.edu > Please tick the applicable situation 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: 2 Signing I have completed this form truthfully. 2.1 Name Please write down your name as stated in your passport, current place, date and signature. 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.

2 Please complete if you are a degree-seeking student. If you are an exchange student you do not need to complete this page. (degree-seeking students) AUTHORIZATION FORM FOR THE STUDY PROGRESS MONITORING 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:

3 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) 1.1 Application for a permit for the purpose of work, wealthy foreign national, learning while working or study? 1.2 V-number (if known) Leave this blank. 1.3 Name Surname as stated in the border-crossing document Tick yes Yes No First names 1.4 Sex and Date of birth > Please tick the applicable situation Male Female 1.5 Place of birth 1.6 Country of birth 1.7 Nationality Day Month Year Complete as requested. 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- Number Country

4 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! 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 Name Surname as stated in the border-crossing document First names Sex > Please tick the applicable situation Male Female Home address Street Number Nationality Postcode Town Only complete if you have a spouse or (registered) partner that will be traveling with you and that will be living in the Netherlands. 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 2.2 Place and date 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 Place Day Month Year Day Month Year Complete as requested Leave blank

5 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

6 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: