Name

XXX

Sex

Male

Date of Birth

X^th August, 19XX

Date of arriving this city

XX^th 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 XX^th December, 200X to XX^th 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