MCC Application Form (version 12/18) - page 3

Personal details

1. Are you the migrant, family member of the migrant or representative?

Migrant Family Member Representative

2a. Applicant’s first name or names as stated on the application form:

2b. Applicant’s last name or family name as stated on the application form:

3. Applicant’s date of birth:

D D M M Y Y Y Y

4. Applicant’s nationality:

5. What type of visa, leave to enter or remain does the applicant currently have or have an outstanding application for?

- vist

- work

- study

- family

- EEA residence permit or card

- settlement

- other (please tell us what):

6. What is the applicant making changes to?

Application details before decision

Application details after decision

MCC Application Form (version 12/18) - page 4

7. PBS or Home Office reference number (if known):

8. Application reference number (if known):

9. Representative reference number (if known):

Type of change10. Please indicate the type of change required:

Personal details - go to Q11 Representative’s details - go to Q24

Criminal convictions - go to Q13 Dependants’ details - go to Q26

Contact details - go to Q18 Other - go to Q28

Personal details11. Description of change:

12. Date change becomes effective:

D D M M Y Y Y Y

Criminal convictions13. Nature of the criminal offence or the civil action (give details on a separate sheet and enclose it with this form if more space is needed):

MCC Application Form (version 12/18) - page 5

14. Details of the sentence or civil judgment (give details on a separate sheet if more space is needed):

15. Date of sentence/judgment:

D D M M Y Y Y Y

16. Country where the sentence was passed or the civil judgment was made:

17. Please provide details if the applicant has been charged in any country with a criminal offence for which they have not yet been tried in court:

Contact details18. Full address:

19. Postcode:

20. Home telephone number:

21. Mobile telephone number:

22. Work telephone number:

23. Email address:

MCC Application Form (version 12/18) - page 6

Representative’s details

24. Description of change:

25. Date change becomes effective:

D D M M Y Y Y Y

Dependant’s details

26. Description of change:

27. Date change becomes effective:

D D M M Y Y Y Y

Other changes

28. Description of change:

29. Date change becomes effective:

D D M M Y Y Y Y

DeclarationI hereby declare that the information given in this form is true and correct to the best of my knowledge and belief.

Name:

Signature: Date:

D D M M Y Y Y Y