1. Surname (s) (family name(s))
| |
2. Surname(s) at birth
(earlier family name(s))
| Data złożenia wniosku: |
3. First name(s)
| Przyjmujący wniosek:
|
4. Date of birth (year-month-day)
| 5.Number of ID document (optional)
|
Dodatkowe dokumenty:
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6. Place and country of birth
|
Ważny dokument
podróży |
7. Current nationality/ies
| 8. Original nationality (nationality at birth)
|
Środki finansowe
Zaproszenie |
9. Sex
Male
Female
| 10. Marital status
Single
Married
Separated
Divorced
Widow(er)
Other
|
Środek transportu
Ubezpieczenie
zdrowotne
|
11. Father’s
name
| 12. Mother’s
name
|
Inne:
|
|
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13. Type of travel document
National passport
Diplomatic passport
Service passport
Travel document (1951 Convention)
Alien’s passport
Seaman’s passport
Other travel document (please specify):
..........................................................................................................................................
| Wiza:
Odmowa
Wydana
Typ wizy:
|
14. Number of passport
| 15. Issued by |
LTV
A
|
16. Date of issue
| 17. Valid until |
B
C
|
18. If you reside in a country other than your country of origin, do you have permission to return to that country?
No
Yes (number and validity) ......................................................................................
| ð
D
ð
D+C
|
* 19. Current occupation
|
|
* 20. Employer and employer’s address and phone number. For students,
name and address of school
|
|
|
|
21. Destination country
| 22. Type of visa
Airport
Transit
Short stay
Long stay
| 23. Visa
Individual
Collective
........(how many persons)
| Ilość wjazdów:
1
2
wiele
Ważna od ........................
do ....................................
|
24. Number of entries requested
Single entry
Two entries
Multiple entries
| 25. Duration of stay:
Visa requested for __________ days
|
|
26. Other visas
(issued within the past 3 years) and their period of validity:
| Ważna w:
....................................
|
27.
If you are in transit, do you have an entry permit for the final country
of destination?
No
Yes, valid until :
Issued by:
|
|
* 28. Previous stays in the Republic of Poland or other Schengen states
|
|
| | | | | | | |
29. Purpose of travel
Tourism
Business
Visit to family or friends
Cultural/Sports
Official
Medical reasons
ð Work
Education
Other (please specify):
..........................................................................................................................................
| Wypełnia
organ wydający wizę |
|
|
* 30. Date of entry | * 31. Date of departure
|
|
* 32. Border of first entry or transit route
| * 33. Means of transport |
|
|
|
* 34. Name of host person
or company in the Schengen states and contact person in host company. If not applicable – name of hotel or temporary address in the Schengen states: |
|
Name | Phone and fax |
|
Full address | E-mail address |
|
|
|
* 35. Who is covering the costs of your travel and stay?
Applicant
Host person
Host company
(Please specify who, how and enclose corresponding documentation) .............................................................................................................................................. ..............................................................................................................................................
|
|
* 36. Means of support during your stay
Cash
Travellers cheques
Credit cards
Accommodation
Other:
Travel and/or health insurance. Valid until:
...............................................................................
|
|
|
|
37. Spouse’s family name |
38. Spouse’s family name at birth |
|
39. Spouse’s first name |
40. Spouse’s date of birth |
41. Spouse’s place of birth
|
|
42. Children (application must be submitted separately for each passport)
Surname
First name
Date of birth
1
.............................................................................
.......................................................
.................................
2
.............................................................................
.......................................................
.................................
3
.............................................................................
.......................................................
.................................
|
|
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43. Personal data of the EU or EEA citizen you depend on. This question should be answered
only by family members of EU or EEA citizens. |
|
Surname | First name | |
Date of birth | Nationality | Number of passport |
Relationship: ........................................................................................................ of an EU or EEA citizen. |
|
|
44.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.
At my express request,
the 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 Polish law.
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 Polish law.
If a visa is granted, I undertake to leave the territory of the Schengen states
not later than
the last day of the visa’s validity.
I am aware that possession of a visa
is only one of the prerequisites for entry into the territory of the Schengen states.
The 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 refused entry. The prerequisites for entry will be checked
again on entry into the territory of the Schengen states.
.
|
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45. Applicant’s home address | 46. Telephone number
|
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47. Place and date | 48. Signature (for minors, signature of custodian/guardian)
|
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