N14076*01

* 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 e!ercisin" their ri"ht to free
mo#ement$ %amily members of EU, EEA or CH citizens shall present documents to pro#e this relationship and fill in fields no &' and &($

(! %ields )*& shall be filled in in accordance with the data in the tra#el document$
)$ +urname (%amily name (!
,$ +urname at birth (%ormer family name(s (!
&$ %irst name(s (-i#en name(s (!
'$ .ate of birth
(day*month*year

($ /lace of birth 0
1$ Country of birth 0
2$ Current nationality 0
3ationality at birth, if different0 0

4$ +e!

5ale %emale
6$ 5arital +tatus
+in"le 5arried +eparated .i#orced 7idow(er
8ther (please specify
)9$ :n the case of minors0 +urname, first name, address (if different from applicant;s and nationality of parental
authority<le"al "uardian


))$ 3ational identity number, where applicable 0
),$ Type of tra#el document
8rdinary passport .iplomatic passport +er#ice passport 8fficial passport +pecial passport
8ther tra#el document (please specify 0

)&$ Tra#el document number


)'$ .ate of issue )($ =alid until )1$ :ssued by
)2$ Applicant;s home address and e*mail address



Telephone number(s
)4$ >esidence in a country other than the country of current nationality
3o ?es 0 >esidence permit or e@ui#alent 3ABBBBBBB$BB$BB=alid untilBBBBBB$$B$

* )6$ Current occupation
* ,9$ Employer and employer;s address and telephone number$ %or students, name and address of educational
establishment$


,)$ 5ain purpose(s of the Courney 0
Tourism Dusiness =isitin" family or friends Cultural +ports 8fficial #isit +tudy
5edical reasons Transit Airport transit 8ther (please specify 0
,,$ 5ember +tate(s of destination ,&$ 5ember +tate of first entry
,'$ 3umber of entries re@uested
+in"le entry Two entries 5ultiple entries
,($ $ .uration of the intended stay or transit
:ndicate number of days 0

,1$ +chen"en #isas issued durin" the past three years
3o
?es$ .ate(s of #alidity BBBBBB<BBBBB$$, BB$BB$B<BBBBBB, B$$BBB$$<BBBBB

,2$ %in"erprints collected pre#iously for the purpose of applyin" for a +chen"en #isa
3o ?es$ .ate, if known 0 BBBBBBBBBBBBBBBBBBBBBBBB$
,4$ Entry permit for the final country of destination, where applicable
:ssued byBBBBBBBBBBBB$BBB, #alid fromBBBBBBBBBBB$$untilBBBBBBBBBBB
For official use only

.ate of application 0


=isa application number 0


%ile handled by 0


Application lod"ed at 0
E Embassy<consulate
E CAC
E +er#ice pro#ider
E Commercial intermediary
E Dorder

3ame 0

E 8ther


+upportin" documents 0

E Tra#el document
E 5eans of subsistence
E :n#itation
E 5eans of transport
E T5:
E 8ther0



=isa decision 0
E >efused

E :ssued 0
E A
E C
E FT=

E =alid 0

%romBBBBBBBBBB

UntilBBBBBBBBBB$

3umber of entries 0
E ) E , E 5ultiple

3umber of days 0 BBBBB$


Application for Schengen visa
This application form is free
PHOTO

,6$ :ntended date of arri#al in the +chen"en area &9$ :ntended date of departure from the +chen"en area


* &)$ +urname and first name of the in#itin" person(s in the 5ember +tate(s$ :f not applicable, name of hotel(s or temporary accommodation(s in the
5ember +tate(s

Address and e*mail address of in#itin" person(s<hotel(s<temporary accommodation(s



Telephone and telefa!

* &,$ 3ame and address of in#itin" company<or"anisation



Telephone and telefa! of
company<or"anisation
+urname, first name, address, telephone, telefa!, and e*mail address of contact person in company<or"anisation


* &&$ Cost of tra#ellin" and li#in" durin" the applicant;s stay is co#ered

by the applicant himself<herself

5eans of support
Cash
Tra#ellerGs che@ues
Credit card
/re*paid accommodation
/re*paid transport
8ther (please specify 0
by a sponsor (host, company, or"anisation,
/lease specify
referred to in field &)or &,
other (please specify 0 BBBBBBBBBBBBBB$B$
5eans of support
Cash
Accomodation pro#ided
All e!penses co#ered durin" the stay
/re*paid transport
8ther (please specify 0
&'$ /ersonal data of the family member who is an EU, EEA or CH citizen
+urname

%irst name(s
.ate of birth 3ationality

3umber of tra#el document or :. card

&($ %amily relationship with an EU, EEA or CH citizen 0
spouse child "randchild dependent ascendant

&1$ /lace and date

&2$ +i"nature (for minors, si"nature of parental authority < le"al "uardian



: am aware that the #isa fee is not refunded if the #isa is refused$

Applicable in case a multiple*entry #isa is applied for (cf$ field no ,'0
: am aware of the need to ha#e an ade@uate tra#el medical insurance for my first stay and any subse@uent #isits to the territory of 5ember +tates$

: am aware of and consent to the followin"0 the collection of the data re@uired by this application form and the takin" of my photo"raph and, if applicable, the takin" of
fin"erprints, are mandatory for the e!amination of the #isa applicationH and any personal data concernin" me which appear on the #isa application form, as well as my
fin"erprints and my photo"raph will be supplied to the rele#ant authorities of the 5ember +tates and processed by those authorities, for the purposes of a decision on
my #isa application$
+uch data as well as data concernin" the decision taken on my application or a decision whether to annul, re#oke or e!tend a #isa issued will be entered into, and stored
in the =isa :nformation +ystem (=:+
)
for a ma!imum period of fi#e years, durin" which it will be accessible to the #isa authorities and the authorities competent for
carryin" out checks on #isas at e!ternal borders and within the 5ember +tates, immi"ration and asylum authorities in the 5ember +tates for the purposes of #erifyin"
whether the conditions for the le"al entry into, stay and residence on the territory of the 5ember +tates are fulfilled, of identifyin" persons who do not or who no
lon"er fulfil these conditions, of e!aminin" an asylum application and of determinin" responsibility for such e!amination$ Under certain conditions the data will be also
a#ailable to desi"nated authorities of the 5ember +tates and to Europol for the purpose of the pre#ention, detection and in#esti"ation of terrorist offences and of other
serious criminal offences$ The authority of the 5ember +tate responsible for processin" the data is0 Commission Nationale de l'Informatique et des Liberts 8, rue
Vivienne 75083 !"I# $ede% 0&
: am aware that : ha#e the ri"ht to obtain in any of the 5ember +tates notification of the data relatin" to me recorded in the =:+ and of the 5ember +tate which
transmitted the data, and to re@uest that data relatin" to me which are inaccurate be corrected and that data relatin" to me processed unlawfully be deleted$ At my
e!press re@uest, the authority e!aminin" my application will inform me of the manner in which : may e!ercise my ri"ht to check the personal data concernin" me and
ha#e them corrected or deleted, includin" the related remedies accordin" to the national law of the +tate concerned$ The national super#isory authority of that 5ember
+tate (Commission Nationale de l'Informatique et des Liberts 8, rue Vivienne 75083 !"I# $ede% 0& will hear claims concernin" the protection of personal data$
: declare that to the best of my knowled"e all particulars supplied by me are correct and complete$ : am aware that any false statements will lead to my application bein"
reCected or to the annulment of a #isa already "ranted and may also render me liable to prosecution under the law of the 5ember +tate which deals with the application$
: undertake to lea#e the territory of the 5ember +tates before the e!piry of the #isa, if "ranted$ : ha#e been informed that possession of a #isa is only one of the
prere@uisites for entry into the European territory of the 5ember +tates$ The mere fact that a #isa has been "ranted to me does not mean that : will be entitled to
compensation if : fail to comply with the rele#ant pro#isions of Article (() of >e"ulation (EC 3o (1,<,991 (+chen"en Dorders Code and : am therefore refused
entry$ The prere@uisites for entry will be checked a"ain on entry into the European territory of the 5ember +tates$

/lace and date +i"nature (for minors, si"nature of parental authority<le"al "uardian0

() :nsofar as the =:+ is operational

1
$