Application for Schengen Visa This application form is free
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1. Surname (Family name) (x)
FOR OFFICIAL USE ONLY
2. Surname at birth (Former family name(s)) (x)
Date of application:
3. First name(s) (Given name(s)) (x)
Visa application number:
4. Date of birth (day-month-year)
5. Place of birth 6. Country of birth
8. Sex
9. Marital status
□ Male □ Female
Application lodged at Embassy/consulate CAC Service provider Commercial intermediary Border Divorced
7. Current nationality Nationality at birth, if different:
□ Single □ Married □ Separated □ □ Widow(er) □ Other (please specify)
□ □ □ □ □
Name:
□ Other 10. In the case of minors: Surname, first name, address (if different from applicant’s) and nationality of parental authority/legal guardian
11. National identity number, where applicable
Supporting documents:
12. Type of travel document
□ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport □ Special passport □ Other travel document (please specify) 13. Number of travel document
14. Date of issue
15. Valid until
17. Applicant’s home address and e-mail address
16. Issued by
Telephone number(s)
18. Residence in a country other than the country of current nationality
□ No
□ Yes
File handled by:
□ Residence permit or equivalent ……………………..………………………….. No. ……………….………………… Valid until….………………………….
* 19. Current occupation
□ Travel document □ Means of subsistence □ Invitation □ Means of transport □ TMI □ Other: Visa decision:
□ Refused □ Issued: □A □C □ LTV □ Valid:
From ……………………………. Until …………………………….
* 20. Employer and employer’s address and telephone number. For students, name and address of educational establishment.
Number of entries:
□ 1 □ 2 □ Multiple 21. Main purpose(s) of the journey:
□ Tourism □ Business □ Visiting family or friends □ Cultural □ Sports □ Official visit □ Medical reasons □ Study □ Transit □ Airport transit □ Other (please specify)
Number of days:
22. Member State(s) of destination
23. Member State of first entry
24. Number of entries requested
25. Duration of the intended stay or transit Indicate number of days
□ Single entry □ Two entries □ Multiple entries
The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields No 34 and 35. (x) Fields 1-3 shall be filled in in accordance with the data in the travel document. 26. Schengen visas issued during the past three years
□ No □ Yes □ Date(s) of validity from …………………………….. to …………………..………………….….. 27. Fingerprints collected previously for the purpose of applying for a Schengen visa
□ No
□ Yes
Date, if known …………………….………..……………
28. Entry permit for the final country of destination, where applicable Issued by ……………………………….. Valid from ……………………until …………………..…………. 29. Intended date of arrival in the Schengen area
30. Intended date of departure from the Schengen area
* 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 State(s)
Address and e-mail address of inviting person(s)/hotel(s)/temporary accommodation(s)
Telephone and telefax
* 32. Name and address of inviting company/organisation
Telephone and telefax of company/organisation
Surname, first name, address, telephone, telefax, and e-mail address of contact person in company/organisation
* 33. Cost of travelling and living during the applicant’s stay is covered
□ by the applicant himself/herself Means of support
□ Cash □ Traveller’s cheques □ Credit card □ Prepaid accommodation □ Prepaid transport □ Other (please specify) .………………......…
□ by a sponsor (host, company, organisation), please specify □ referred to in field 31 or 32 …………………………………… □ other (please specify) ………………………………….……… Means of support
□ Cash □ Accommodation provided □ All expenses covered during the stay □ Prepaid transport □ Other (please specify)………………………………………….
34. Personal data of the family member who is an EU, EEA or CH citizen Surname Date of birth
First name(s) Nationality
Number of travel document or ID card
35. Family relationship with an EU, EEA or CH citizen
□ spouse □ child □ grandchild □ dependent ascendant 36. Place and date
37. Signature (for minors, signature of parental authority/legal guardian)
I am aware that the visa fee is not refunded if the visa is refused. Applicable in case a multiple-entry visa is applied for (cf. field No 24): I am aware of the need to have an adequate travel medical insurance for my first stay and any subsequent visits to the territory of Member States. I am aware of and consent 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 processed by those authorities, for the purposes 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 purposes of verifying whether the conditions for the legal entry into, stay and residence on the territory of the Member States are fulfilled, of identifying persons who do not or who no longer fulfil these 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 purpose of the prevention, detection and investigation of terrorist offences and of other serious criminal offences. The authority of the Member State responsible for processing the data: Ministry of Foreign Affairs, Loretánské náměstí 5, CZ-118 00 Praha 1; Directorate of Alien Police, Olšanská 2, P.O. BOX 78, CZ-130 51 Praha 3 and Ministry of the Interior, Nad Štolou 3, CZ-170 34 Praha 7. 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 processed unlawfully be deleted. At my express request, the authority examining my application will inform me of the manner in which I may exercise 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 that Member State will hear claims concerning the protection of personal data: Office for Personal Data Protection, Pplk. Sochora 727/27, CZ-170 00 Praha 7. I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution 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 possession 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 refused entry. The prerequisites for entry will be checked again on entry into the European territory of the Member States.
Place and date
_________________ 1
In so far as the VIS is operational.
Signature (for minors, signature of parental authority/legal guardian):
ýíslo žádosti / Application number
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ěSCPP þ.
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3,5 x 4,5 cm
8
2007
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Razítko úĜadu / Stamp of Embassy or Consulate
Žádost o udČlení schengenského víza Tento formuláĜ je zdarma
Application for Schengen Visa This application form is free of charge 1. PĜíjmení / Surname(s) (Family name(s))
Pro úĜední úþely
2. Ostatní jména (pĤvodní pĜíjmení) / Surname(s) at birth (earlier family name(s))
For Embassy / Consulate use only
3. KĜestní jméno(a) / First names (given names) Datum podání:
4. Datum narození (ddmmrrrr) / Date of birth (ddmmyyyy) 5. ýíslo obþanského prĤkazu / ID-number (optional) Zpracováno kým:
6. Místo narození / Place of birth
ZemČ narození (kód) / Country of birth (code) 7. Souþasná(é) státní pĜíslušnost(i) (kód) / Current nationality(ies) (code) 8. Státní pĜíslušnost pĤvodní (kód) / Original nationality (nationality at birth) (code) 9. Pohlaví / Sex mužské / Male ženské / Female 10. Rodinný stav / Marital status svobodný(á) / Single ženatý-vdaná / Married žijící oddČlenČ / Separated rozvedený (á) / Divorced ovdovČlý(á) / Widow(er) jiný / Other 11. Jméno a pĜíjmení otce / Father's name
Platný pas
Finanþní prostĜedky
Pozvání
12. Jméno a pĜíjmení matky / Mother's name 13. Druh cestovního pasu nebo cestovního dokladu / Type of passport Cestovní pas / National passport Diplomatický pas / Diplomatic passport Služební pas / Service passport Cestovní doklad (Ženevská konvence 1951) / Travel document (1951 Convention) Cizinecký pas / Alien's passport NámoĜnický pas / Seaman's passport Jiný cestovní doklad (prosím uvećte) / Other travel document (please specify) 14. ýíslo pasu / Number of passport
DoplĖující dokumenty:
Dopravní prostĜedky
Zdravotní pojištČní
Další:
15. Vystaven kým (kód) / Issued by (code)
16. Datum vystavení (ddmmrrrr) / Date of issue (ddmmyyyy) 17. Platný do (ddmmrrrr) / Valid until (ddmmyyyy) 18. Jestliže se zdržujete v jiné než domovské zemi uvećte oprávnČní k návratu pro zemi bydlištČ. If you reside in a country other than your country of origin, have you permission to return to that country? Ne / No
Vizum: Odmítnuto
UdČleno
Ano (þíslo) / Yes (number) Doba platnosti (ddmmrrrr) / Validity (ddmmyyyy)
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Pro úĜední úþely
*19. Souþasné povolání / Current occupation
For Embassy / Consulate use only
*20 . ZamČstnavatel (název školy) / Employer (Name of school)
Druh víza:
Adresa zamČstnavatele (školy) / Address of employer (school)
LTV
Telefon zamČstnavatele / Telephone number of employer
A B
21. Hlavní cíl cesty / Main destination
C
22. Druh víza / Type of Visa Letištní tranzit / Airport transit Tranzit / Transit
Krátkodobý pobyt / Short stay Dlouhodobý pobyt / Long stay
23. Vízum / Visa Samostatné / Individual
Skupinové / Collective
D
24. Poþet požadovaných vstupĤ / Number of entries requested jednorázovČ / Single entry na dvČ cesty / Two entries vícerázovČ / Multiple entries
C+D
Poþet vstupĤ: 1 2
25. Doba pobytu / Duration of stay vízum je žádáno na / Visa is requested for
více
dní / days
26. PĜedchozí víza (udČlená v posledních tĜech letech) a jejich platnost Other visas (issued during the past three years) and their period of validity
Platné od:
27. V pĜípadČ tranzitu máte povolení k pĜicestování do cílového státu? In the case of transit, have you an entry permit for the final country of destination? Ano, platné do (ddmmrrrr) Ne / No / Yes, valid until Vystaven kým / Issuing authority
Do:
Platné pro:
*28. PĜedchozí pobyty v tomto a dalších schengenských státech / Previous stay in Schengen states Stát (kód) / Country (code)
Od (ddmmrrrr) / From (ddmmyyyy)
29. Úþel cesty / Purpose of travel Turistika / Tourism Obchod / Business Kulturní, sportovní / Cultural, sports NavštČva rodiny nebo pĜátel / Visit to family or friends
Do (ddmmrrrr) / Until (ddmmyyyy)
ÚĜední / Official Zdravotní dĤvody / Medical reasons Jiné dĤvody / Other
Jiné dĤvody (uvećte jaké) / Other (please specify)
*30. Datum pĜíjezdu (ddmmrrrr) / Date of arrival (ddmmyyyy) *31 . Datum odjezdu (ddmmrrrr) / Date of departure (ddmmyyyy) *32. Hranice prvního vstupu nebo trasa prĤjezdu / Border of first entry or transit route *33. Dopravní prostĜedek / Means of transport
* Otázky oznaþené * nemusí být zodpovČzeny þleny rodin obþanĤ EU (Evropská unie) nebo EHP (Evropský hospodáĜský prostor) (manžel(ka), dítČ, þi ekonomicky závislí pĜíbuzní v pĜímé linii). Rodinní þlenové obþanĤ EU nebo EHP musí doložit dokumenty, které tuto pĜíbuznost potvrdí. * The questions marked with * do not have to be answered by family members of EU or EEA citizens (spouse, child or dependent ascendant). Family members of EU or EEA citizen have to present documents to prove this relationship. Strana/Page
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*34. Jméno a pĜíjmení zvoucí osoby, zvoucí firmy v Schengenských státech a kontaktní osoba ve firmČ. V jiných pĜípadech uvećte název hotelu nebo adresu pĜechodného pobytu v Schengenských státech. Name of host or company in the Schengen states and contact person in host company. If not applicable, give name of the hotel or temporary address in the Schengen states.
Pro úĜední úþely For Embassy / Consulate use only
Jméno a pĜíjmení osoby/ Name of person Název firmy (hotelu) / Name of company (hotel) Úplná adresa / Full address Telefon / Telephone
FAX / FAX
E-mailová adresa / E-mail address *35. Kdo pĜebírá Vaše cestovní a ubytovací náklady? / Who is paying for your cost of travelling and for your costs of living during your stay? Žadatel / Myself Zvoucí osoba(y) / Host person(s) Zvoucí firma / Host company Uvećte kdo a jak a pĜedložte odpovídající doklady / State who and how and present corresponding documentation *36. Finanþní prostĜedky k živobytí po dobu pobytu / Means of support during your stay Finanþní hotovost / Cash
Šeky (cestovní) / Traveller's cheques
Platební karty / Credit cards
Ubytování / Accommodation
Ostatní / Other Ostatní (Specifikujte napĜ. doklad o ubytování) / Other (specify) Cestovní a/nebo zdravotní pojištČní / Travel and/or health insurance
platné do (ddmmrrrr) / valid until (ddmmyyyy)
Manžel (-ka) / Spouse 37. PĜíjmení / Spouse's family name 38. Rodné pĜíjmení / Spouse's family name at birth 39. Jméno / Spouse's first name
40. Datum narození (ddmmrrrr) / Spouse's date of birth (ddmmyyyy) 41. Místo narození / Spouse's place of birth 42. DČti (pro každý cestovní pas musí být podána samostatná žádost)
Children (Applications must be submitted separately for each passport)
a. PĜíjmení / Name Jméno / First name
Datum narození (ddmmrrrr) / Date of birth (ddmmyyyy)
b. PĜíjmení / Name Jméno / First name
Datum narození (ddmmrrrr) / Date of birth (ddmmyyyy)
c. PĜíjmení / Name Jméno / First name
Datum narození (ddmmrrrr) / Date of birth (ddmmyyyy)
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43. Osobní údaje týkající se obþana EU nebo EHP (evropský hospodáĜský prostor), který Vás vyživuje. Tato otázka by mČla být zodpovČzena pouze rodinnými pĜíslušníky obþanĤ EU nebo EHP. Personal data of the EU or EAA citizen you depend on. This question should be answered only by family members of EU or EEA citizens. PĜíjmení / Name Jméno / First name Datum narození (ddmmrrrr) / Date of birth (ddmmyyyy)
Státní pĜíslušnost (kód) / Nationality (code)
ýíslo cestovního pasu / Number of passport Rodinný pomČr obþana EU nebo EHP: / Family relationship of an EU or EEA citizen: 44. 44.
Jsem si vČdom a souhlasím s následujícím: jakékoliv mé osobní údaje uvedené v této žádosti o vízum budou poskytnuty pĜíslušným úĜadĤm schengenských státĤ a jimi v pĜípadČ potĜeby použity za úþelem rozhodnutí o mé žádosi o vízum. Takovéto údaje mohou být vloženy do databází a uschovány v databázích pĜístupných pĜíslušným úĜadĤm v rĤzných schengenských státech. Na mou výslovnou žádost mČ konzulární úĜad vyĜizující mou žádost bude informovat o zpĤsobu, jakým mohu uplatnit své právo zkontrolovat své osobní údaje, nechat je pozmČnit þi vymazat, zejména pokud by byly nepĜesné, v souladu se zákony uvedeného státu. Prohlašuji podle svého nejlepšího vČdomí, že všechny mnou uvedené údaje jsou správné a úplné. Jsem si vČdom, že jakékoliv chybné údaje povedou k zamítnutí mé žádosti þi ke zrušení již udČleného víza a mohou mČ rovnČž vystavit trestnímu stíhání podle zákonĤ toho schengenského státu, jenž žádost vyĜizuje. Zavazuji se opustit území schengenských státĤ po vypršení platnosti víza, bude-li mi udČleno. Byl jsem informován o skuteþnosti, že udČlení víza je jen jednou z podmínek vstupu na evropské území schengenských státĤ. Pouhá skuteþnost že mi bylo udČleno vízum, neznamená, že budu mít nárok na odškodnČní, pokud nesplním pĜíslušná ustanovení þlánku 5.1 Schengenské provádČcí úmluvy a bude mi tudíž odmítnut vstup. Podmínky nutné pro vstup budou znovu pĜekontrolovány pĜi mém vstupu na evropské území schengenských státĤ. I am aware of and consent to the following: any personal data concerning me which appear on this visa application form will be supplied to the relevant authorities in the Schengen states and processed by those authorities, if necessary, for the purposes of a decision on my visa application. Such data may be input into, and stored in, databases accessible to the relevant authorities in the various Schengen states. At my express request, the consular authority processing my application will inform me of the manner in which I may exercise my right to check the personal data concerning me and have them altered or deleted. in particular, should they be inaccurate, in accordance with the national law of the state concerned. I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution under the law of the Schengen state which deals with the application. I undertake to leave the territory of the Schengen states upon the expiry of the visa, if granted. I have been informed that possession of a visa is only one of the prerequisites for entry into the European territory of the Schengen 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 the Schengen Implementing Convention and am thus refused entry. The prerequisites for entry will be checked again on entry into the European territory of the Schengen states.
45. Domovská adresa žadatele / Applicant's home address 46. Telefonní þíslo / Telephone number 47. Místo / Place
Datum (ddmmrrrr) / Date (ddmmyyyy)
48. Podpis žadatele ( u nezletilých podpis zákonného zástupce):: Applicant's Signature (for minors, signature of custodian/guardian)::
Místo pro nalepení kontrolní þásti vízového štítku
……………………………………………………………. Podpis pracovníka vydávajícího vízum
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