Annex A Harmonised application form Application for Schengen Visa This application form is free Family members of 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 2. Surname at birth (Former family name(s)}: Date of application: 3 First name(s) (Given name(s) Application number: [No logo is required for Norway, Iceland, Liechtenstein and Switzerland.Date of birth 5. Place of birth 7.Current Application lodged (day-month-year): nationality: at: 6. Country of birth Nationality at D birth, if different: | Embassy/consulate Other 15 Service provider nationalities: Commercial intermediary 8. Sex: 9. Civil status: Border (Name): 1 Male 1 Female 1D Single 0 Married 0 Registered Partnership a Separated o Divorced 11 Widow(er) 1 Other (please specify): © Other: 10. Parental authority (in case of minors) /legal guardian (surname, first File handled by: name, address, if different from applicant's, telephone no., e-mail address, and nationality) 11. National identity number, where applicable: Supporting documents: 12. Type of travel document: 1 Travel document 10 Ordinary passport © Diplomatic passport « Service passport 1 Official passport 1 Special passport © Means of subsistence 10 Other travel document (please specify): Invitation413. Number of | 14. Date ofissue: | 15. Valid until: | 16. Issued by travel document: (country) 17. Personal data of the family member who is an EU, EEA or CH citizen or an UK national who is a Withdrawal Agreement beneficiary, if applicable Surname (Family name): First name(s) (Given name(s}: Date of birth Nationality: Number of travel (day-month-year): document or ID card: 18, Family relationship with an EU, EEA or CH citizen or an UK national who is a Withdrawal Agreement beneficiary, if applicable: 10 spouse 11 child «i grandchild c dependent ascendant 10 Registered Partnership c other: 19. Applicant's home address and e-mail address: Telephone no. 20. Residence in a country other than the country of current nationality: No 11 Yes. Residence permit or equivalent... No. Valid until T™I Means of transport 2 Other: Visa decision: Refused Issued: ou Valid: From: Until"21. Current occupation: Number of entries: * 22. Employer and employer's address and telephone number. For students, | ‘9120 Multiple name and address of educational establishment: Number of days: 23, Purpose(s) of the journey: 1D Tourism 3 Business & Visiting family of friends © Cultural 0 Sports 6 Official Visit 1 Medical reasons a Study © Airport transit o Other (please specify} 24, Additional information on purpose of stay: 25, Member State of main destination | 26. Member State of first entry: (and other Member States of destination, if applicable) 27. Number of entries requested 1D Single entry © Two entries © Multiple entries Intended date of arrival of the first intended stay in the Schengen area: Intended date of departure from the Schengen area after the first intended stay:28. Fingerprints collected previously for the purpose of applying for a Schengen visa: « Noo 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): ‘Address and e-mail address of Telephone no. inviting person(s)/hotel(s)/temporary accommodation(s}:"31, Name and address of inviting company/organisation: Surname, first name, address, Telephone no. of telephone no., and e-mail address of | company/organisation: contact person in company/organisation: "32. Cost of travelling and living during the applicant's stay is covered: a by the applicant himself/herself 2 bya sponsor (host, company, organisation), please specify Means of support: referred to in field 30 Cash or 31.......0 other (please specify): 10 Traveller's cheques Means of support: Credit card a Cash 10 Pre-paid accommodation 2 Accommodation provided 10 Pre-paid transport All expenses covered during the stay 10 Other (please specify) = Pre-paid transport © Other (please specify):| am aware that the visa fee is not refunded if the visa is refused. Applicable in case a multiple-entry visa is applied for: | am aware of the need to have an adequate travel medi subsequent visits to the territory of Member States. al insurance for my first stay and any | 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 con 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 ((...lam aware that | 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 | 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 national supervisory authority of that Member State (contact, details: seve Will hear claims concerning the protection of personal data, | declare that to the best of my knowledge all particulars supplied by me are correct and complete. | 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. | undertake to leave the territory of the Member States before the expiry of the visa, if granted. | 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 | will be entitled to compensation if! fail to comply with the relevant provisions of Article 6(1) of Regulation (EU) No 2016/399 (Schengen Borders Code) and | 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 applicable}