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Harmonised application form Application for

Schengen Visa 3.50cm x 4.50cm
This application form is free

Family members of the EU, EEA or CH citizens or of UK nationals who are Withdrawal Agreement beneficiaries shall
not fill in fields no.21,22,30,31 and 32 (marked with*).
Fields 1-3 shall be filled in in accordance with the data in the travel document.

1. Surname (Family name): FOR OFFICIAL USE ONLY

DIMANE
Date of application:

2. Surname at birth (Former family name(s)): Application number:

Application lodged at:

3. First name(s) (Given name(s)):
RYMA □Embassy/consulate
4. Date of birth (day-month-year): 5. Place of birth: 7.Current nationality: □ Service provider
ALGERIENNE □ Commercial
06/01/1989 SIDI MHAMED Nationality at birth, if intermediary □
6. Country of birth: different: Border (Name):
ALGERIE ………………
Other nationalities: □ Other:

File handled by:

8. Sex:
9. Civil status: Supporting documents:
□ Travel document
✓ Single □ Means of subsistence
□ Male
□ Married □ Invitation
✓ Female □ TMI
□ Registered Partnership □ Means of transport □
Other:
□ Separated

□ Divorced Visa decision:

□ Refused □
□ Widow(er)
Issued:
□ Other (please specify): □A
□C
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different □ LTV
from applicant's, telephone no., e-mail address, and nationality):
□ Valid:
From:
Until:
11. National identity number, where applicable:
Number of entries:
□ 1 □ 2 □ Multiple
12. Type of travel document:
Number of days:

✓ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport

□ Special passport

□ Other travel document (please specify):

13. Number of travel 14. Date of issue: 15. Valid until: 16. Issued by
document: (country):

186677656 20/05/2018 19/05/2028 ALGERIE

17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who is a
Withdrawal Agreement beneficiary, if applicable:

Surname (Family name): First name(s) (Given name(s)):

Date of birth (day month year): Nationality: Number of travel document or

ID card:

18. Family relationship with an EU, EEA or CH citizen or a UK national who is a Withdrawal
Agreement beneficiary, if applicable:

□ spouse
□ child
□ grandchild
□ dependent ascendant
□ Registered Partnership □
other
19. Applicant's home address and e mail Telephone no.:
address:

CITÉ 100 LOGEMENTS BATIMENT H, 213 696 00 36 68

DRARIA, ALGER

20. Residence in a country other than the country of current nationality:

✓ No
□ Yes. Residence permit or equivalent ………………… No. …………………….. Valid
until……………

*21. Current occupation:

ENSEIGNANTE DE LANGUE FRANÇAISE

* 22. Employer and employer’s address and telephone number. For students, name and address of
educational establishment:
ÉCOLE PRIMAIRE TAKARLI ABDELGHAN –
RUE TAKARLI ABDELGHANI, DARARIA, ALGER

23. Purpose(s) of the journey:

✓ Tourism
□ Business s
□ Visiting family or friends
□ Cultural
□ Sports
□ Official visit
□ Medical reasons
□ Study
□ Airport transit
□ Other (please specify):
24. Additional information on purpose of stay:

25. Member State of main destination (and other 26. Member State of first entry:
Member States of destination, if applicable):
FRANCE
MALTE

27. Number of entries requested:

□ Single entry
□ Two entries
✓ Multiple entries

Intended date of arrival of the first intended stay in the Schengen area: 01/11/2024

Intended date of departure from the Schengen area after the first intended stay: 07/11/2024

28. Fingerprints collected previously for the purpose of applying for a Schengen visa:

✓ No
□ Yes
Date, if known …………………….. Visa sticker number, if known
…………………………………………………………

29. Entry permit for the final country of destination, where applicable:

Issued by ………………………………..

Valid from ……………………until ……………………

* 30. 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):

IBIS STYLES ST PAULS BAY MALTA

Address and e mail address of inviting Telephone no:

person(s)/hotel(s)/temporary accommodation(s):
356 21660000
HALEL STREET BUGIBBA – SPB2528
ST. PAUL’S BAY – MALTE

[email protected]
*31. Name and address of inviting company/organisation:

Surname, first name, address, telephone no, and Telephone no of company/organisation:

e mail address of contact person in
company/organisation:

*32. Cost of travelling and living during the applicant’s stay is covered:

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

Means of support: please specify:
✓ Cash ……. □ referred to in field 30 or 31 /
□ Traveller’s cheques ……. □ other (please specify): / Means
□ Credit card of support:
✓ Pre paid accommodation □ Cash
✓ Pre paid transport □ Accommodation provided
□ Other (please specify): □ All expenses covered during the stay
□ Prepaid transport □ Other (please
specify):

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:

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 application; and any personal data concerning me which appear on the
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 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) 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: jointly the Ministry of Foreign and European Affairs and
Trade and Identity Malta Agency.
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 Member State concerned. The Office of the Information and Data Protection
Commissioner ([email protected]) 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 6(1) of Regulation (EU) No 2016/399 (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:

(Signature of parental authority/legal guardian, if
ALGER LE : applicable):