Name

XXX

Sex

Male

Date of Birth

Xth August, 19XX

Date of arriving this city

XXth March, 200X

Permanent residence address

XXX Road, XXX District, XXX City, XXX Province

Temporary residence address

Student’s dormitory within the courtyard of XXX University, Family Members Committee

 of XXX University

Present service unit

XXX College of the XXX University

ID Card No.

00000000000000

Valid period

From XXth December, 200X to XXth December, 200X

No.

C000000000000000

Registration for change of temporary residence address

Move-out date

Move to (address)

Move-in date

Postpone registration

Date

Check condition

Check unit