Solicitare de viza Application for Visa - Travel Document · "Operator de date cu caracter personal notificat sub numarul 5285" Solicitare de viza Application for Visa Formular gratuit/This

"Operator de date cu caracter personalnotificat sub numarul 5285"

Solicitare de vizaApplication for Visa

Formular gratuit/This appli(~ation form is free

TIP DE VIZA: Ai Bi C

1. Numele/Surname(s) (familyname(s))

FOR EMBASSY /CONSULATE USEONLY

2. Numele lanaStere/Slirname(s) at birth (earlier family name(s»Data solicitarii :

3. Prenume/First names (given names)

4. Data nasterii/Date of birth (day-month-year) 5. CNP/lD-nnmber Document procesat de :

6. Locul si tara nasteriil Place and country of birth

9. Sexul/SexOBarbatesc/Male 0 Femeiesc/Fernale

Documente doveditoare:

0 Pasaport vaJabil

7. Cetatenia prezenta/Cnrrent nationality/ies 8. Cetatenia la nastere/Original nationality (nationality at birth) 0 Mijloace flnanciare

f.J Invitatie[::1 Mijloace de transport

110. Statut civil/Marital status .f.~.l Bilet de calatorie

i 0 CelibatarlSingle 0 Casaiont/Manied [,.;1 Asigurare?e S~tate, r...1 Dovada as1guran1

0 d 0 .conditiilor de cazare

SeparntlSeparate D1vortatlDiVorcedI 0 E ti " /.Jtcep 1: (se va conp eta

infanctie de do(umentele

0 Vaduv(a)/Widow(er)O Altele/Other vrezentate de solicitan~ inconformitate ca art.40 dinO. UC. 194/2002))11. Numele tataluilFather's name 12. Numele mameiMother's name

13. Document de calatorierrype of passport:

OPasaport diplomatic/Diplomatic passport OPasaport turistic:JNational passport

0 Pasaport de serviciu/Service passport 0 Document de calatorie pentru refugiatifTraye1 document (1951 Cony.)

OPasaport pentru straini/Alien's passport OCarnet de marinar/Searnan's passport

OAltele (specificati)/Other travel document (please specify):

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14. Nr. de pasaport/Number of passport 15. Emis de/Issued by

16. Data emiterii/Date of issue (day-month-year) 17. Valabil palla la/Valid until(day-month-year)

18. Daca aveti domiciliul in sIt stat decat cel de origine, va este permis sa va reintoarceti in acest stat/If you reside in acountry other than your country of origin, have you permission to return to that country?

0 Nu/No 0 Da (nmnaml si valabilitatea pemlis itmii)N es, (number andvalidi~~ :.,=.,., =c'."19. Fuuctia ocupata in prezent/ Current occupation

Viza20. A11gajatorul, adresa acestuia si nr. de tel. Pentru elevi si studenti, denumirea si adresa institutiei dernvatamant/Employer and employer's address and telephone number. For students, name and address of school d Acordata

21. Destinatia principala/Main destination1 22. Tipul de viza/fype of Visa :0 Tranzit aeroporwar/Airpon ttan.'!it0 TranzitJTransit0 Scurta sedere/ short stay

Tipul de viza :

'8~r::.1 c25.Durata sederiil Duration of stay

Nr.deintrari:D1[J2[J

Valabila de 1a

MultipleViza solicitata pt.Nisa is requested for: zile/days

[14. Nr. de intrari soJicitate/No. of entries requested0 Unica intrare/Single entry0 Doua intrari/fwo entries0 Multiple intrari/Multiple entries

26:: Alte vize emise in ultimii 3 ani si valabi~r/Othervisas (issued during the past three years) and their period ofvalidity. La

27 .In cazul uneiv~iranzit, detineti permisiunea de a calatori in statui de destinatie/ln the case of transit, have youan entry permit for the final country of destination?

0 Nu/No 0 Da, valabiIa pam IaN es , valid until:Ernisa de /Issuing authority:

28. Sederi anterioare in Romania/Previous stays in Romania

first entry or transit route

34.Dennmirea firmei romane de contact si a persoanei responsabile i n cadrnl acesteia. absenta, denumirea hoteluluisan adresa temporara in Romania! Name of host or company in Romania and contact person in host company.lfnotapplicable, give name of hotel or temporary address in Romania.

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Adresa completa/FuIl address e-maiJ/e-mail address

o. 0.0. 35. Cine suporta cheltuielile de deplasare si de sedere in Romania/Who is payIng for your cost of travelling and for your

I costs oflivillg during your stay? 0 Subsemnatul/Myself 0 Persoana fizica rornanalHost person(s)

0 Persoanajuridica romana(numiti cine si anexati documente doveditoare)/Host company. (State who and howand present corresponding documentation):

0 Carti de credit/Credit cards

Valid until:

37. Numele sotului(sotiei)/Spouse's family name 38. Numele la nastere al sotului(sotiei)/ Spouse's familyname at birth

39. Prenumele sotului(sotiei)/ 40.Data de nastere a sot 41. Locul de nastere al sotului(sotiei)/Spouse's first name Spouse's date of birth (day-month-year) Spouse's place of birth

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44. Dae a aveti alte rude in Romania?/lf you have any relatives in Romania?

45. Am luat la cunostinta umlatoarele: toate datele personate cu privire la subsernnatul(a) care apar in prezentul fonnular vor fivuse la dispozitia autoritatilor romane competente si procesate de catre acestea, dupa caz, in scopul luarii unci decizii cu privire la

: prezenta solicitare de viza. Aceste date pot fi introduse si stocate in bazele de date accesibile autoritatilor romane competente.I Unnare solicitarii exprese a subsernnatului, autoritatile consulare menite sa proceseze prezenta solicitare ma vor infOTml cu

vrivire la rnodalitatea in care imi pot exercita dreptul de a veri fica datele personale fumizate, de a dispune rnodificarea sauindepartarea lor, daca se dovedesc incorecte, in conformitate cu prevederile legislatiei in vigoare in Romania. Declar ca, dupastimta mea, toate datele fumizate sunt corecte si complete. Declar ca am cunostinta de faptul ca orice date false furnizate conducla respingerea prezentei solicitari sau la anularea vizei emise in baza acestora si pot duce la declansarea urnlaTirii mele penale inconformitate cu legea romana. Ma oblig sa parasesc teritoriul Romaniei la expirarea vizei ce mi-a fost acordata. Am fost infOTmltca detinerea vizei nu reprezinta decat una dintre conditiile de indeplinit pentru intrarea in Romania. Simpla eliberare a vizei nuDresupune faptul ca sunt indreptatit(a) la primirea unor compensatii daca nu indeplinesc conditiile prevazute la Capitolul I I(Dispozitii generale privind intrarea, sederea si iesirea strainilor) al OUG 194/2002 si imi este refuzata intrarea in Romania.Indeplinirea conditiilor de intrare va fi supusa verificarii la rnomentul intrarii pe teritoriul Romaniei.//I am aware of and consent to the following: any personal data concerning me which appear on this visa application fonn will besupplied to the relevant authorities in Romania and processed by those authorities, if necessary, for the purposes of a decision onmy visa application. Such data may be input into, and stored in, databases accessible to the relevant authorities in Romania. Atmy express request, the consular authority processing my application will inform me of the manner in which I may exercise myright to check the personal data concerning me and have them altered or deleted, in particular, should they be inaccurate, in

I 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 andmay also render me liable to prosecution under the Romanian law which deals with the application.I undertake to leave the territory of Romania upon the expiry of the visa, if granted. 1 have been informed that possession of a visais only one of the prerequisites for entry into the European territory of the Schengen states. The mere fact that a visa has been~ted to me does not mean that 1 will be entitled to compensation if I fail to comply with the relevant provisions of Chapter I 1(General provisions regarding entry, stay and exit of aliens) ofGEO no. 194/2002 and am thus refused entry. The prerequisites forentry will be checked again on entry into the territory of Romania.

46. Adresa de domiciliu a solicitantului/Applicant's home address 47. Nr.de telJPhone no.

48. Data la (locul si data)/Place and date (day-month-year)

~'unt de accord cu pre/ucrarea date/or prezentate inconformitate cu Legea 677/2001(1 agree with the processing of data presented inaccording with Law no. 677/2001)(Je suis d 'accord avec /e traitement des donnes presenteesconformement a/a Loi no. 677/2001)

49. Semnatura (pentru minori, semnaturareprezentantului legal)/Signature (for minors,signature of custodian/guardian)