Schengen Visa Application form aTkuaws
1. Surname (Family name) (x) 3 For official u only
kuR `
2. Surname at birth (Former family name (s) (x) _I3X
Date of application: 3. First name (s) (Given name (s) (x) '
Visa application number: 4. Date of birth (day-month-year) _HO (H -M ->) 5. Place of birth / _- 6. Country of birth / _+ 7. Current nationality / ^+l Nationality at birth, if different: _I+l 2 ^+l & Application lodged at Embassy/Consulate
CAC
Service provider
Commercial intermediary
8. Sex / A Male / c Female / 1 9. Marital status / 54] Single / P5 Married / =5 Separated / ; Divorced / h? Widow (er) / Other / 8 ……………………………. Border
Name:
Other
10. In the ca of minors: Surname, first name, address (if different from applicant’s) and nationality of parental authority / legal guardian / PB>aw ~/ %YfC e3' .(2 aw &) "+
File handled by:
11. National identity number, where applicable y u$g 2z` Supporting documents: Travel document
12. Type of travel document C[im Ordinary passport / L{C[ Diplomatic passport / 0 C[ Service passport / C[ Official passport / * C[ Special passport / \WC[ Other (plea specify) / 8Gru wZJ …………………………………… Means of subsistence Invitation
Means of transport
TMI
Other:
13. Number of travel document Gru n$
14. Date of issue k#HO 15. Valid until NEOp 16. Issued by k#R
17. Applicant’s home address and e-mail address aw ."b6| Telephone number(s) bv$g 18. Residence in a country other than the country of current nationality K(; ,^I+l 0e+9 No ( Yes. Residence permit or equivalent …………………… No ………………… Valid until..………………………….. K ;du n$ NEOp Visa decision: Refud
Issued
A
C
LTV
*19. Current occupation ^o
*20. Employer and employer’s address and telephone number. For students, name and address of educational establishment. < ! 'j -.)bv 7_/ 7S'j"-.
Valid
From ………………………
Until ………………………
This application form is free
VsU xD
21. Main purpo(s) of the journey: _
Tourism / _x Business / 0! Visiting Family or Friends / X ' Cultural / \" Sports / Official visit / C^ ª
Medical reasons / $ Study / A Transit / £8
Airport transit / i5£8
Other (plea specify) / B ( tb Number of entries:
1 2 Multiples Number of days:
(x) Fields 1-3 shall be filled in accordance with the data in the travel document
@q1-3 ¬ W_ 7 ¡]
22. Member State (s) of destination / }n 423. Member State of first entry / ¯ }n2
24. Number of entries requested } 8o[
Single entry / o Multiple entries / ;o Two entries / o 25. Duration of the intended stay or transit Indicate number of days
¤ S£8a[
The fields marked with * shall not be filled by family members of EU, EEA or CH citizens (spou, child or dependent ascendant) while exercising their right to free movement. Family members of EU, EEA or CH citizens shall prent documents to prove this relationship and fill in fields No 34 and 35.
p pu w#Sy9 r EMR/(§ ?<S¢ ) |Pl j Q1 I * * ª® p pu w#Sy9 r EMR/Q¬7 34k&35k ª®KY b H \
26. Schengen visas issued during the past three years / £% J U }n
No / sf
Yes. Date (s) of validity from ………………………………………. to …………………………………………..
f fZg|
27. Fingerprints collected previously for the purpo of applying for a Schengen visa P} }n c.fV O
No / sf Yes f …………………Date, if known / =f bag……………….
28. Entry permit for the final country of destination, where applicable e- 4 8 )
Issued by ………………….……...…………… Valid from ……………………………until ………………………………
(i fZg|
29. Intended date of arrival in the Schengen area
D 8}n2ag 30. Intended date of departure from the Schengen area
D N}n2ag
*31. Surname and first name of the inviting person (s) in the Member State (s). If not applicable, name of hotel (s) or temporary accommodation (s) in the Member States (s)
}n2 ¥ >, =`¥
7 }n2 ¨LSd GT,
Address and e-mail address of inviting person (s) / hotel (s) / temporary
accommodation (s) ¥ /¨L/d GT 46&~@¦
Telephone and telefax ~ & *
*32. Name and address of inviting company / organization ¥ +Sim, &46Telephone and telefax of company / organisation ¥ ^~ & *
Surname, first name, address, telephone, telefax, and e-mail address of contact person in company / organisation ¥ +/im >, 46 ~ &~?¦
*33. Cost of traveling and living during the applicant’s stay is covered
_ &32: g« zv {
by the applicant himlf/herlf / ij} O
Means of support / O QG
Cash / e
Traveller’s cheques / RyOp
Credit card / h&
Prepaid accommodation / w B
Prepaid transport / w
Other (plea specify) / @(}`T) by a sponsor (host, company, organisation), plea
Specify / i # } -JYZ O }`T
referred to in field 31 or 32 / (d>^31)32
other (plea specify) / @ (}`T)
Means of support / O QG
Cash / e
Accommodation provided / N B
All expens covered during the stay / O RqV
KUFO
Prepaid transport / w
Other (plea specify) / @(}`T)
34. Personal data of the family member who is an EU, EEA or CH citizen
AEI1 ]n ]aub$Jf7 _ }5 H
Surname <First name(s) /
Date of birth / gSV Nationality
/
2s Number of travel document or ID card
Ry| J !|v,
35. Family relationship with an EU, EEA or CH citizen j} ]n ]aub$Jf7 _l t
spou child …….………………………. grandchild dependent ascendant
=;? ;+
36. Place and date / 3$)SV37. Signature (for minors, signature of parental authority/legal guardian)
r> WID i mL r
I am aware that the visa fee is not refunded if the visa is refud / X o ' r|zM x r|~
Applicable in ca a multiple-entry visa is applied for (cf. field No24): / h j}9\ 6r| ((d>^24)
I am aware of the need to have an adequate travel medical insurance for my first stay and any subquent visits to the territory of Member Status.
X o 8U : lRc%k \) 0.\ *"j[2A 4 h
I am aware of and connt to the following: the collection of the data required by this application form and the taking of my photograph and, if applicable, the taking of fingerprints, are mandatory for the examination of the visa application; and any personal data concerning me which appear on the visa application form, as well as my fingerprints and my photograph will be supplied to the relevant authorities of the Member States and procesd by tho authorities, for the purpos of a decision on my visa application.
Such data as well as data concerning the decision taken on my application or a decision whether to annul, revoke or extend a visa issued will be entered into, and stored in the Visa Information System (VIS) (1) for a maximum period of five years, during which it will be accessible to the visa authorities and the authorities competent for carrying out checks on visas at external borders and within the Member States, immigration and asylum authorities in the Member States for the purpos of verifying whether the conditions for the legal entry into, stay and residence on the territory of the Me
mber States are fulfilled, of identifying persons who do not or who no longer fulfill the conditions, of examining an asylum application and of determining responsibility for such examination. Under certain conditions the data will be also available to designated authorities of the Member States and to Europol for the purpo of the prevention, detection and investigation of terrorist offences and of other rious criminal offences. The authority of the Member State responsible for processing the data is: Ministry of Foreign Affairs, Consular Affairs and Migration Policy Department (DCM), Postbus 20061, 2500 EB DEN HAAG
I am aware that I have the right to obtain in any of the Member States notification of the data relating to me recorded in the VIS and of the Member State which transmitted the data, and to request that data relating to me which are inaccurate be corrected and that data relating to me processing unlawfully be deleted. At my express request, the authority examining my application will inform me of the manner in which I may exerci my right to check the personal data concerning me and have them corrected or deleted, including the related remedies according to the national law of the State concerned. The national supervisory authority of the Netherlands will hear claims concerning the protection of personal data: [College Bescherming Persoonsgegevens, Postbus 93374, 2509 AJ DEN HAAG]
I declare that to the best of my knowledge all particulars supplied by me are corrected and completed. I am aware that any fal statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to procution under the law of the Member State which deals with the application.
I undertake to leave the territory of the Member States before the expiry of the visa, if granted. I have been informed that posssion of a visa is only one of the prerequisites for entry into the European territory of the Member States. The mere fact that a visa has been granted to me does not mean that I will be entitled to compensation if I fail to comply with the relevant provisions of Article 5(1) of Regulation (EC) No 562/2006 (Schengen Borders Code) and I am therefore refud entry. The prerequisites for entry will be checked again on entry into the European territory of the Member States.
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Cϼ½Y JÄÑ4w ¨#éå 1gSÓ vu GK;a à¥ÃÊ Ç8ÔÕ¸¦Ñ¹4wÝã Ç8]%Ý Ministry of Foreign Affairs, Consular Affairs and Migration Policy Department (DCM), Postbus 20061, 2500 EB DEN HAAG.
1 @%1 0 H8 =5& @VIS C J+ 1 $L.< =5& + > K7 L1 0 = /6C + > $! K 9 $ 41 = > 23 1 H8* ? -# $L = G 4 $> L )? =5& >9" H8/6;' K 6A> $> G ? =5& > BI $ 9= > F BI . [College Bescherming Persoonsgegevens, Postbus 93374, 2509 AJ DEN HAAG]
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Place and date / XH K Signature (for minors, signature of parental authority/legal guardian)
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() In so far as the VIS is operational
