Annex APPLICATION FORM FOR REGISTRATION CERTIFICATE OF OPERATION (REPRESENTATIVE/PROJECT OFFICE) Concerning issuance, extension, amendment, modification of certificate Full name of Organization: Nationality: Vietnamese counterpart agencies (If available): Address of Headquarter: Tel: Fax: Email: Mandate and Objectives: Financial resources and budget: Programmes, projects or plans of activities (approved by Vietnamese competent authorities in case of Rep/Project Office) in Vietnam: Intended locations of operation in Vietnam: Purpose for establishing rep/Project Office in Vietnam: 10.Name of Head of Rep/Project Office or the person authorized by the relevant INGO : Date of Birth: Passport No: Contact address in Vietnam (Tel, Fax, Email): 11.Number of Expatriate and Vietnamese staff proposed: 12.We are committed to strictly abide by the Vietnamese laws in force as well as Decree No 12/2012/ND-CP on registration and management of operations of INGOs in Vietnam Done at , date Signature of applicant stamp (Full Name)