N° 14076*01

Application for Schengen visa PHOTO

This application form is free

For official use only

1. Surname (Family name) (x) GHATH
Date of application :
2. Surname at birth (Former family name(s)) (x) GHATH
Visa application number :
3. First name(s) (Given name(s)) (x) MILAD
File handled by :
4. Date of birth 5. Place of birth : 7. Current nationality :
(day-month-year) LIBYAN ARAB JAMAHIRIYA
6. Country of birth : Nationality at birth, if different: : Application lodged at :
10-01-1960 LIBYAN ARAB JAMAHIRIYA LIBYAN ARAB JAMAHIRIYA □ Embassy/consulate
8. Sex 9. Marital Status □ CAC
Single X Married Separated Divorced Widow(er) □ Service provider
X Male Female □ Commercial intermediary
Other (please specify) □ Border
10. In the case of minors: Surname, first name, address (if different from applicant's) and nationality of parental
authority/legal guardian Name :

□ Other
11. National identity number, where applicable :
12. Type of travel document Supporting documents :
X Ordinary passport Diplomatic passport Service passport Official passport Special passport □ Travel document
Other travel document (please specify) : □ Means of subsistence
□ Invitation
13. Travel document number 14. Date of issue 15. Valid until 16. Issued by □ Means of transport
LIBYAN ARAB □ TMI
PZH4R9F6 08-09-2015 07-09-2023 JAMAHIRIYA □ Other:

17. Applicant's home address and e-mail address Telephone number(s)

SUQ ALKHAMIS SOQ ALKHAMIS 91171, [email protected] 218913500866
Visa decision :
□ Refused

□ Issued :
18. Residence in a country other than the country of current nationality □A
□C
X No Yes : Residence permit or equivalent N°………………….…….……Valid until………………..…. □ LTV

* 19. Current occupationWHITE-COLLAR WORKER □ Valid :

From…………………………
* 20. Employer and employer's address and telephone number. For students, name and address of educational
establishment. Until………………………….
NATIONAL OIL COORPORATION, BASHIR SADAWI STREET TRIPOLI 91171, 213350401
Number of entries :
□ 1 □ 2 □ Multiple
21. Main purpose(s) of the journey :
Tourism X Business Visiting family or friends Cultural Sports Official visit Study Number of days : …………….

Medical reasons Transit Airport transit Other (please specify ) :

22. Member State(s) of destination 23. Member State of first entry
FRANCE FRANCE
24. Number of entries requested 25. . Duration of the intended stay or transit
Single entry Two entries X Multiple entries Indicate number of days :
19
26. Schengen visas issued during the past three years
X No
Yes. Date(s) of validity ………………/…………….., …….…….…/………………, …..………../……………

27. Fingerprints collected previously for the purpose of applying for a Schengen visa
X No Yes. Date, if known : ……………………………………………………………….
28. Entry permit for the final country of destination, where applicable
Issued by……………………………….………, valid from……………………………..until……………………………
* The fields marked with * do not need to 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.
29. Intended date of arrival in the Schengen area 30. Intended date of departure from the Schengen area
25-02-2018 15-03-2018

* 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

FAURE HERMAN, ROUTE DE BONNETABLE LA FERTE BERNARD BP 20154, FRANCE company/organisation
33243602860
33243602870
Surname, first name, address, telephone, telefax, and e-mail address of contact person in company/organisation
ARTHUR GOARIN, ROUTE DE BONNETABLE LA FERTE BERNARD BP 20154, 33243602860

* 33. Cost of travelling and living during the applicant's stay is covered

by the applicant himself/herself X by a sponsor (host, company, organisation),

Please specify
Means of support X referred to in field 31or 32
Cash other (please specify) : …………………………………….….
Traveller’s cheques Means of support
Credit card Cash
Pre-paid accommodation Accomodation provided
Pre-paid transport X All expenses covered during the stay
Other (please specify) : Pre-paid transport
Other (please specify) :
34. Personal data of the family member who is an EU, EEA or CH citizen
Surname
First name(s)
Date of birth 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 is: Commission Nationale de l'Informatique et des Libertés – 8, rue
Vivienne – 75083 PARIS cedex 02
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 (Commission Nationale de l'Informatique et des Libertés – 8, rue Vivienne – 75083 PARIS cedex 02) 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):

(1) Insofar as the VIS is operational

1.