annex sd 40-9 shape id card application leaving shape... · nato unclassified/ releasable to...
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NATO UNCLASSIFIED/ RELEASABLE TO INTERNET - PERSONAL IN CONFIDENCE (WHEN COMPLETED) TO BE COMPLETED ELECTRONICALLY
In-processing form (SF94 - JUNE 2016) is also available for download, at: http://www.shape2day.com/arriving--leaving-shape/inprocessing.aspx
SF 94 - JUNE 2016
ANNEX SD 40-9
SHAPE ID CARD APPLICATION All personnel must be in possession a valid National Passport/Military ID Card when applying for a SHAPE ID Card
Part 1 Personal Details (applicable to all)
Name (Surname first)
Marital Status (2)
Maiden Name
Date of Marriage
Rank/Title
Place of Marriage
Gender
Service (3)
Country of Birth & Town
Type of Member (4)
Nationality (1)
Date of arrival in Belgium
Date of Birth
Date of departure:
State of Birth (US and Canada only)
NATO Rank
Part 2 Employment Details (not applicable for dependents)
Authorized post number (PE)
Branch
Posting Start Date
Bldg.
Posting End Date
Rm.
Division
Tel. Ext
Part 3 For dependents only (tick as appropriate) - please attach supporting notes/official documentation*
Name of the holder (titulaire) SHAPE ID CARD Nr./Post Number
Relationship with the holder (titulaire)
Spouse
Son
Daughter
*Civil Partnership
*Cohabitation
*Other
Part 4 Other details: complete where applicable
Have you been registered in Belgium
Yes
No From: To:
Do you hold any valid Belgium Id
Yes
No From:
To:
Do you intend to reside in Belgium? If “yes” please indicate your current or future address. If “no”, leave the box blank.
Yes
City/post code/name street Nr.
No
Last address abroad City/post code/name street Nr.
Tel. number/and GSM
Email address (official/personal)
Part 5 Situation related to vehicles imported in Belgium where applicable.
How many vehicles will you bring into Belgium and plate number
Nr.
Plate Nr:
Plate Nr:
Part 6 SHAPE Language Testing Centre, Linguistic Services (Bldg 101, Room M104/105) For Military Personnel Assigned to an ACO PE Post
Language test Yes - No
Presented him/herself with a valid English language proficiency certificate OR signed up for an English language proficiency test
Date: Stamp & Signature, SLTC
Applicant’s declaration
ANY FALSE DECLARATION MAY RESULT IN THE LOSS OF SHAPE PRIVILEGES AND/OR IMMUNITIES. I UNDERSTAND THAT SHOULD ANY SUBSEQUENT INFORMATION ASCERTAINED BY SHAPE OR HOST NATION OFFICIALS REVEAL THAT I AM NOT ENTITLED TO RECEIVE SHAPE PRIVILEGES AND/OR IMMUNITIES, SUCH PRIVILEGES AND/OR IMMUNITIES CAN BE WITHDRAWN AND BELGIAN AUTHORITIES ARE EMPOWERED TO DEMAND REIMBURSEMENT OF APPLICABLE TAXES.
Applicant’s signature
Certified by
Stamp/Date/Signature (NMRs/SU/J1 CHRM/SHAPE NCIA/ACTSEE)
(stamp of entitled authority) See SD 40-9 (Annex A1)
Determination Individual’s Legal Status and Classification
SHAPE BSG - FSCEP - REGISTRATION
SECTION (BLDG 210 - RM.110) TO BE COMPLETED BY BSG/FSCEP/RGN Personnel ONLY Type of Member
Type of Card
Stamp/Date/Signature Matrix Status & Entitlements. APMS - Nr.
Remarks:
Nr. (to be numbered in order to permit a MIN FIN verification). BEL SID - Mod P or S. Request Nr. (if applicable):
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NATO UNCLASSIFIED/RELEASABLE TO INTERNET - PERSONAL IN CONFIDENCE (WHEN COMPLETED) TO BE COMPLETED ELECTRONICALLY
SF94 (Pag. 2) - JUNE 2016
ANNEX SD 40-9
1. NATIONALITY
NATO MEMBERS
ALB ALBANIA BEL BELGIUM BGR BULGARIA CAN CANADA HRV CROATIA CZE CZECH REPUBLIC DNK DENMARK EST ESTONIA FRA FRANCE DEU GERMANY GRC GREECE HUN HUNGARY ISL ICELAND ITA ITALY LVA LATVIA LTU LITHUANIA LUX LUXEMBOURG NLD NETHERLANDS NOR NORWAY POL POLAND PTR PORTUGAL ROU ROMANIA SVK SLOVAKIA SVN SLOVENIA ESP SPAIN TUR TURKEY GBR UNITED KINGDOM USA UNITED STATES
PFP MEMBERS
ARM ARMENIA AUT AUSTRIA AZE AZERBAIJAN BLR BELARUS FIN FINLAND FYR FYROM GEO GEORGIA IRE IRELAND KAZ KAZAKHSTAN KGZ KYRGYSTAN MDA MOLDOVA RUS RUSSIA SWE SWEDEN CHE SWITZERLAND TJK TAJIKISTAN TKM TURKMENISTAN UKR UKRAINE UZB UZBEKISTAN
MEDITERRANEAN DIALOGUE
DZA ALGERIA EGY EGYPT ISR ISRAEL JOR JORDAN MRT MAURITANIA MAR MOROCCO TUN TUNISIA
CONTACT COUNTRIES COL COLOMBIA AUS AUSTRALIA
2. MARITAL STATUS
A MARRIED B CIVIL PARTNERSHIP C SINGLE D DIVORCED
E WIDOW(ER) 3. SERVICE
A ARMY AF AIR FORCE C CIVILIAN N NAVY M MARINES
4. TYPE OF MEMBER
MIL MILITARY NIC NATO CIVILIAN CIV COMP NATIONAL CIVILIAN COMPONENT DEP DEPENDENT
CON CONSULTANT INT INTERNSHIP CCS CONCESSIONAIRES SAT SATELLITE
SFP FEDERAL POLICE LWF LOCAL WORK FORCE LWR LOCAL WAGE RATE LWS LOCAL WAGE SCALE
DIP DIPLOMAT PFP PARTNERSHIP FOR PEACE
SIS SHAPE INTERNATIONAL SCHOOL CTR IHP US CONTRACTOR INDIRECT HIRE
TDY TEMP NATO DUTY (TRAVEL ORDER IS REQUIRED)
OTH OTHERS
AMENDMENTS/COMMENTS Users of this form are invited to send amendments/comments and suggested improvements to SHAPE J1-MOR - SHAPE Bldg.101
In-processing form (SF94 - JUNE 2016) is also available for download, at: http://www.shape2day.com/arriving--leaving-shape/inprocessing.aspx
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