� YOUR BOSTON ADDRESS 1.18 *»!f±:W: 1.19 ro�i!&fAiulil½ 02134 r Home address Zip Code

1.2oit!i:St-'f-:tl. (555) 123-4567 1.21 it! ro�ffi'f [email protected] Home/mobile phone number E-mail address 1.22 �ffi:fjc(ir. Marital status □ Bffi Married [{] i(!:Ji;j Single D ;lt-ftl!. Other(Please specify): ·- Name Wffi Nationality !Ill�Occupation :ie* Relationship 1.23 .:t�*»!JvG tt� .!'A (lfrH/ll, 'f-:k, � x:-HJ�.AJ) :%£1£ JOHN SMITH AMERICAN TEACHER FATHER Major family members(spouse, MARY SMITH BRITISH DOCTOR MOTHER children, pa1·ents, etc., (DO NOT LIST SIBLINGS) may type on separate paper) ,. 1.24 tt� MARY Sl\lllTH -'f-;tfl, (555) 987-6543 �f&��Am ,� Name Mobile phone number Emergency $ :ie* q trA a

2.1 $ffi'A:il*EB 0 q*W¾�!llG*�1Pt1W*jr,_Mffi��a.l�•ra:tE*W�l¥i'r.!l-1¥i'a.J�*EB-tE*WMli'aChina As accompanying family member of foreigner residing clueto work, study or other reasons in China clueto wo1·k, study or other reasons ◄, [{] mM�>.J Short-term study for less than 180 clays D i<:M�>.I Long-term study for over 180 clays ?'rW'm!Jt*W�liil:tl.fiiffil* D ��o;/!!s�for temporary news coverage □ As resident journalist ·- D ;lt-ftl!.(�i#.IJ/J)Other (Please specify): r -­.... [{] -{X( §�'.&:z.13 jlQ 31-Jj1f:i'&) One entry valid for 3 months f om the elate of issne =tX(§�'.&:z.13 jlQ 3-61-Jj1f %0 Two entries valid for 3 to 6 months from the elateof issue 2.2 tttiJA�tX� □ Intenclecl number #-�${X ( §�'.&:z.Bjj'g61-Jl 1f:i'&) Multiple entries valid for 6 months from the elate of issue of entries □ □ -�${X ( §�'.&:z.Bjj'g I �ff:i'&)Multiple entries valid for I year from the elate of issue □ ;)t-ftl!. ( �i#,lj/j) Other (Please specify): 2.3 R,:1§$ffi'1Jll f&BR9}- Are you applying for express service? �. :/.Jo�JlH-@iH$'8'.6Hlti'l, :j(j-1.Joi&Jt.lllo [{] R::Yes □ 1S No Note: Express service needs approval of consular officials, and extra fees may apply. 2.4 *tXtr�BtttittX11£:it*WaDISTRICT, SHANGHAI JlJ !!ft 53 &!£:gli�) CHINA 200437 ltinernry in China (in time sequence, may type on separate paper)

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·- 2. 7 ift�ffeffi.tEq:rWW3i'iiJl¥Jlfhffl? MYSELF AND MY PARENTS Who will pay for your travel and expenses during your stay in China?

tt.;g,i1JG�f$ fOUD..\N U1\l \"ERSlTY SCHOOL OF SOCIAL DEIELOP"1E\JT . .\ND PUBLIC POLICY Name 220 HANDAN RD, SHANGHAI, CHINA 200433 :li!!:l.tl: J 2.s q:rW:!!K P3�ffl Address lji,&i1JG--tA -rn � Information of 862155665470 JfH��-m inviter in China Phone number C

�$ffl.A::X:� INVITER Relationship with the applicant •\ YES, GRANTED 2013-05-09 IN LOS , 2.9 t!i!HttMtl�ftt q:r �fil?m mi�, ffli#.llJl :ltl:llr-��:jij. q:r �fili¥Jat 00 ANGELES i'iiJ;fll:li!!J/R. Have you ever been granted a Chinese visa? If applicable, please specify the date and place of the last time you were granted the visa. - � I ENGLAND,CANADA 2.10 tt¾12 --t q:r1'JfiiJl¥JQm*il!G:li!!IK13 Other countries or territories you visited in the last 12 months "-..

' Q:fl'.:g}i Part 3· Other Information 3.1 �N �tEq:rmilitt�filil!Gr.i.l-1¥i'i?F-JlJftitfi¥JW31lltf!lt\¥i' ? Yes IZ]N No Have you ever overstayed your visa or residence permit in China? Ot!

3.2 t!Ni�1Bl:1E��.£q:rm�fil,il!Gb�:ltl:Aq:r00? t!Y es IZ]1S No Have you ever been refused a visa for China, or been refused entry into China? O 3.3 �:;s;a:q:rmi1JGJ1;.f!Bmnm,i1Ha*1 t!Yes N No Do you have any criminal record in China or any other country? O IZ] 3.4 t!NA�!:J:F-f±-#tl/r% Arc you experiencing any of the following conditions? (DF:i:�1iJll$lij Serious mental disorder Ot!Ye s IZ]N No @��jg;.)lrpf"i!i�m Infectious pulmonary tuberculosis @JlJ��Jit�0:;lt.J?.1:.1¥JJ!;.flB�!,!1!m Other infectious disease of public health hazards 3.5 :ilr 30 S r'ilt!N1wtl:tt¥iittrtt�m�:!41!1¥JW*il!G:!i!!IK? D�Yes IZ]1S No Did you visit countries or territories affected by infectious diseases in the last 30 days? 3.6 :tio;l!@;xt 3.1 �J 3.s 1¥J-tEfiiI---tfiiJJm�1f"t!", wtErliifw�i#.l!Jl. If you select Yes to any questions from 3.1 to 3.5, please give details below. N/A