退出中華人民共和國國籍申請表編號SerialNo.ApplicationforRenunciationofChineseNationality一、個人信息PersonalInformation1.1中文姓名/ChineseName姓/FamilyName:名/GivenName:照片/Photo1.2英文姓名/EnglishNameExactlyAsItAppearsonYourPassport姓/FamilyName:中間名/MiddleName:名/GivenName:1.3別名或曾用名/OtherName(s)1.4性別/Gender￡男/Male￡女/Female1.5出生日期/DateofBirth(yyyy-mm-dd)1.6出生地（國家/城市）/PlaceofBirth(City/Country)1.7婚姻狀況/MaritalStatus￡未婚/Single,NeverMarried￡已婚/Married￡離異/Divorced￡喪偶/Widowed￡其他（請注明）Other(Specify):1.8國內戶口狀況/DomesticHouseholdRegistration￡已登記戶口/RegisteredHousehold￡未登記戶口/UnregisteredHousehold￡戶口已注銷/注銷時間/DateofCancellation:1.9（原）戶口所在地/Placeof(Former)HouseholdRegistration1.10（原）公民身份號碼/(Former)IdentityCardNumber1.11現持中國護照/旅行證件（如有）/CurrentChinesePassport/TravelDocument(ifapplicable)證件種類/TypeofDocument證件號碼/DocumentNumber簽發日期/DateofIssue簽發國家或地區/PlaceofIssue失效日期/DateofExpiry1.12電話號碼/PhoneNumber1.13電子郵箱/E-mail1.14現住址/CurrentPhysicalAddress1.15工作單位/Employer二、申請信息ApplicationInformation2.1退籍事由/ReasonsforRenunciationofChineseNationality￡外國人的近親屬/CloseRelativeofaForeignNational￡配偶/Spouse￡父母/Parents￡子女/Children￡同胞兄弟姐妹/Siblings￡定居在外國/HaveSettledAbroad請詳細說明持何證件、因何事由、定居何國、何時起定居該國/Pleasespecifywhatdocumentyouhold,forwhatreasonandinwhichcountryyouhavesettled,andsincewhenyouhavesettledinthiscountry:￡其它正當理由/Other具體情況/Specify:2.2是否為國家工作人員或現役軍人/Areyouanationalemployeeoranactive-dutymilitarypersonnel？￡是/Yes￡否/No如是，請詳細說明工作單位名稱/Ifyouanswered“Yes”,pleasespecifythenameofyouremployer:Whatnationalitywillyouacquire？2.4是否已取得具有該國國籍的證明文件/Haveyouobtainedanydocumentstoprovethenationalitythatyouwillacquire？￡是/Yes□否/No如是，請選擇證件文件種類/Ifyouanswered“Yes”，pleasechoose:￡國籍證書/NationalityCertificate￡護照/Passport￡其他旅行證件/OtherTravelDocument(s)2.5如已取得外國護照或其他旅行證件，請填寫種類、號碼、簽發日期、簽發國家或地區及失效日期/Ifyouhaveobtainedaforeignpassportortraveldocument,pleaseindicateitstype,number,dateofissue,placeofissue,anddateofexpiry.證件種類/TypeofDocument證件號碼/DocumentNumber簽發日期/DateofIssue簽發國家或地區/PlaceofIssue失效日期/DateofExpiry2.6本次申請是否為首次退籍申請/Isthisafirst-timerenunciationapplication？￡是/Yes￡否/No如否，請詳細說明前次退籍申請時間、申請事由、受理機構/Ifyouanswered“No”,pleasespecifythereasonfor,thedateandtheacceptingauthorityofyourpreviousrenunciationapplication: 三、近親屬情況InformationAboutYourCloseRelatives關系/Relationship姓名/Name性別/Gender出生日期/DateofBirth國籍/Nationality職業/Occupation現住址/CurrentPhysicalAddress3.1配偶/Spouse3.2父母/Parents3.3子女/Children3.4同胞兄弟姐妹/Siblings3.5申請人無上述近親屬的，請在下方欄目填寫申請人的法定監護人或其他親屬，注明與申請人的關系及情況信息/Iftheapplicantdoesnothaveanyoftheabove-mentionedcloserelatives,pleaseindicateinthecolumnbelowhisorherlegalguardian(s)orotherrelatives,theirrelationshipstotheapplicantandotherinformation:關系/Relationship姓名/Name性別/Gender出生日期/DateofBirth國籍/Nationality職業/Occupation現住址/CurrentPhysicalAddress四、教育背景Education4.1最高學歷/HighestEducationLevelAchieved￡博士/DoctoralDegree￡碩士/Master’sDegree￡本科/Bachelor’sDegree￡專科/JuniorCollegeGraduate￡高中SeniorMiddleSchoolGraduate￡初中/JuniorMiddleSchoolGraduate￡小學/PrimarySchoolGraduate4.2會說何種語言/LanguageSkills(conversationallevelorabove)4.3自小學以來的學習經歷/EducationSincePrimarySchool起止日期/Period學校名稱/SchoolName學歷/學位/Diploma/Degree專業/Major從/DateFrom到/DateTo五、工作經歷WorkExperience起止日期/Period單位/公司名稱/EmployerName部門/職務/Department/Position從/DateFrom到/DateTo六、本人其他事項AdditionalInformationAboutYou6.1是否為香港特別行政區、澳門特別行政區、臺灣地區居民/AreyouaresidentofHongKongSAR,MacauSARorTaiwan？￡是/Yes￡否/No如是，請詳細說明所持證件種類、號碼/Ifyouanswered“Yes”,pleasespecifythetypeandnumberofthedocumentthatprovesyoutobearesidentofHongKongSAR,MacauSARorTaiwan:6.2是否有被判處刑罰尚未執行完畢情形/Doyouhaveasentencethathasnotyetbeenserved？￡是/Yes￡否/No如是，請詳細說明犯罪罪名、審判機關名稱、判決確定日期、所判處刑罰、刑期、是否處于緩刑、假釋、暫予監外執行狀態/Ifyouanswered“Yes”,pleasespecifythecrime,thejudicialorgan,whenthejudgmentwasmade,thepenalties,lengthofthepenalties,andwhetheryouareinastateofprobation,parole,orexecutionoutsideofprison:6.3是否屬于刑事案件被告人、犯罪嫌疑人/Areyouadefendantorsuspectinanycriminalcase？￡是/Yes￡否/No如是，請詳細說明因涉何案、被何機關采取何種刑事強制措施/Ifyouanswered“Yes”,pleasespecifythecriminalcase,thecoercivemeasurestakenbytheauthority,andwhichauthorityitwas:6.4是否在中國有違法犯罪記錄/DoyouhaveanycriminalrecordinChina？￡是/Yes￡否/No如有行政違法行為，請詳細說明何時、何地、有何違法行為，被何機關處以何種行政處罰；如有犯罪記錄，請詳細說明犯罪罪名、判決確定日期、所判處刑罰/Iftherewasanadministrativeviolation,pleasespecifywhenandwhereithappened,whatitwas,andwhatadministrativepenaltywasimposedbywhichauthority;ifthereisacriminalrecord,pleasespecifythecrime,thedateofjudgmentandthepenalties:6.5是否曾是國家工作人員/Haveyoueverbeenanationalemployee?￡是/Yes￡否/No如是，請詳細說明工作單位、擔任職務、離職時間/Ifyouanswered“Yes”,pleasespecifyyouremployer,positionandthedateofresignation:6.6是否曾在中國或其他國家部隊服役/HaveyoueverservedinthemilitaryinChinaorothercountries?￡是/Yes￡否/No如是，請詳細說明服役國家、軍銜、服役時間/Ifyouanswered“Yes”,pleasespecifythecountryofservice,rankinmilitaryandlengthofservice：6.7是否以外籍身份在中國停居留/AreyoustayingorresidinginChinaasaforeignnational？￡是/Yes￡否/No如是，請詳細說明簽證或停留居留證件的種類、號碼、有效期限/Ifyouanswered“Yes”,pleasespecifythetype,numberandexpirydateofyourvisa,staypermitorresidencepermit：6.8是否已被批準在中國永久居留/HaveyouobtainedpermanentresidenceinChinauponapplicationapproved？￡是/Yes￡否/No如是，請詳細說明永久居留身份證號碼、有效期限/Ifyouanswered“Yes”,pleasespecifyyourForeignPermanentResidentIDCardnumberanditsexpirydate:七、其他需說明事項OtherInformationtoBeExplained八、聲明及簽名DeclarationandSignature本人謹此聲明，我已閱讀并理解此表所有內容要求，并愿就所填報信息和申請材料的真實性承擔一切法律責任。IherebydeclarethatIhavereadandunderstoodthecontentsofthisapplicationformandshallbearallthelegalconsequencesfortheauthenticityoftheinformationandmaterialsIprovide.申請人簽名:日期:Applicant’sSignatureDate(yyyy-mm-dd)注：未滿18周歲的申請人由父母或其他法定監護人代簽/Note:Aparentorlegalguardianshouldsignonbehalfofaminorundertheageof18.九、受理機構信息InformationAbouttheAcceptingAuthority受理人簽名:受理時間:年月日受理機構（