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Schengen Visa Application

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1. Surname (Family name) (x) 2. Surname at birth (Former family name(s)) (x) 3. First name(s) (Given name(s)) (x) 4. Date of birth (day-month-year) 5. Place of birth 6. Country of birth 8. S  ex male female 7. Current nationality Nationality at birth, if dierent:

For ocial use only Date of application: Visa application number: Application lodged at Embassy/consulate CAC Service provider Commercial intermediary Border Name:

9. Marital status Single Married v Separated Divorced Widow(er)  Other (please specify)

10. I  n the case of minors: Surname, rst name, address (if dierent from applicants) and nationality of parental authority/legal guardian

Other File handled by:

11. National identity number, where applicable 12. Type of travel document Ordinary passport Diplomatic passport Service passport Ocial passport Special passport Other travel document (please specify) 13. Number of travel document 14. Date of issue 15. Valid until 16. Issued by

Supporting documents: Travel document Means of subsistence Invitation Means of transport TMI Other: Visa decision: Refused: Issued: A C VTBG Valid:

17. Applicants home address:

Telephone number(s):

E-mail address: 18. Residence in a country other than the country of current nationality No Yes Residence permit or equivalent *19. Current occupation *20. E  mployer and employers address and telephone number. For students, name and address of educational establishment. No. Valid until

From: . To: . Number of entries: 1 2 Multiple

21. Main purpose(s) of the journey: Tourism Business Visiting family or friends Cultural Sports Ocial visit Medical reasons Study Transit Airport transit Other (please specify) 22. Member State(s) of destination 23. Member State of rst entry

Number of days:

* The elds marked with * shall not be lled 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 ll in elds no 34 and 35. (x) Fields 1-3 shall be lled in in accordance with the data in the travel document.

24. Number of entries requested Single entry Two entries Multiple entries 26. Schengen visas issued during the past three years No

25. Duration of the intended stay or transit Indicate number of days 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 nal country of destination, where applicable Issued by 29. Intended date of arrival in the Schengen area Valid from until

30. Intended date of departure from the Schengen area

* 31. S  urname and rst 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 of inviting person(s)/hotel(s)/temporary accommodation(s)

Telephone nr:

Email address:

*32. Name and address of inviting company/organization

Telephone and telefax of company/organisation

Surname, rst name, address, telephone, telefax, and e-mail address of contact person in company/organisation

*33. Cost of travelling and living during the applicants stay is covered by the applicant himself/herself by a sponsor (host, company, organisation), please specify: referred to in eld 31 or 32 other (please specify) Means of support Cash Accommodation provided All expenses covered during the stay Pre-paid transport Other (please specify)

Means of support Cash Traveller's cheques Credit card Pre-paid accommodation Pre-paid transport Other (please specify)

34. Personal data of the family member who is an EU, EEA or CH citizen Surname Date of birth Nationality First name(s) Number of travel document or ID card

35. Family relationship with an EU, EEA or CH citizen spouse child grandchild dependent ascendant 36. Place date 37. Signature (for minors, signature of parental authority/legal guardian)

* The elds marked with * shall not be lled 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 ll in elds no 34 and 35.

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. eld no 24): I am aware of the need to have an adequate travel medical insurance for my rst 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 ngerprints, 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 ngerprints 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 ve 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 fullled, of identifying persons who do not or who no longer full 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 oences and of other serious criminal oences. The authority of the Member State responsible for processing the data is: Ministry of Foreign Aairs, Consular Aairs 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 notication 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 [College Bescherming Persoonsgegevens, Postbus 93374, 2509 AJ DEN HAAG] will hear claims concerning the protection of personal data. 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 Signature (for minors, signature of parental authority/legal guardian):

(Endnotes)

Insofar as the VIS is operational.