請求解除限制出境聲請表 Application for the Removal of Restriction from Leaving the ROC 案號： 年度 字第 號 股別： Case No.: year zhi No. Section:
聲請人姓名 Applicant Name	性別 Gender	出生年月日 Date of Birth	國民身分證統一編號 National ID No.	職業 Occupation
Address	Tel.	備考 Remarks
The Request
貴署 年度 偵執字第 號 一案，業經 □不起訴處分確定 □緩起訴處分確定□到 案 執 行，原限制出境之原因，業已消滅，請求准予解除限制 □其 他 出境。 The Case year Jen/Zhi zhi No. of your Office has been □affirmed under a ruling not to prosecute □affirmed under a ruling of deferred prosecution □executed. □Others The reason for the original restriction from leaving the ROC no longer exists. Please grant the removal of the restriction.
此 致 臺灣宜蘭地方檢察署公鑒 TO Taiwan Yilan District Prosecutors Office 聲請人 (簽名蓋章) Applicant (Signature/Stamp) 中 華 民 國 年 月 日 Date: (mm)/ (dd), (yyyy)

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