Ambasciata d’Italia

Addis Abeba
Harmonised application form

Application for Schengen Visa PHOTO

This application form is free

Family members of EU, EEA or CH citizens 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): TESFAYE FOR OFFICIAL USE ONLY

Date of application:
2. Surname at birth (Former family name(s)): N/A
Application number:
3. First name(s) (Given name(s)): YONATAN GEBRE
Application lodged at:
□ Embassy/consulate
Date of birth 5. Place of birth: 7.Current nationality: □ Service provider
(day-month-year): ADDIS ABABA ETHIOPIA □ Commercial intermediary
6. Country of birth: Nationality at birth, if different: □ Border (Name):
24-AUG-1984 ……………………………………
ETHIOPIA □ Other:
Other nationalities:
……………………………………

8. Sex: 9. Civil status: File handled by:

□ Male □ Female □ Single □ Married □ Registered Partnership
Supporting documents:
□ Separated □ Divorced □ Widow(er)
□ Travel document
□ Other (please specify): □ Means of subsistence
□ Invitation
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if
□ TMI
different from applicant’s, telephone no., e-mail address, and nationality):
□ Means of transport
N/A □ Other:
……………………………………

11. National identity number, where applicable: ADDIS ABABA, ETHIOPIA Visa decision:
□ Refused
12. Type of travel document:
□ Issued:
□ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport □A
□ Special passport □ Other travel document (please specify): □C
□ LTV

□ Valid:
13. Number of 14. Date of issue: 15. Valid until: 16. Issued by From:
travel document: 17- AUG- 2026 (country): Until:
18-AUG-2021
EP6642363 ETHIOPIA
Number of entries:
□ 1 □ 2 □ Multiple

Number of days:
17. Personal data of the family member who is an EU, EEA or CH citizen if applicable

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

Date of birth Nationality: Number of travel document

(day-month-year): or ID card:

18. Family relationship with an EU, EEA or CH citizen if applicable:

□ Spouse □ Child □ Grandchild □ Dependent ascendant
□ Registered Partnership □ Other (please specify):

19. Applicant's home address and e-mail address: Telephone no.:

+251911109544

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

□ No

□ Yes. Residence permit or equivalent ……………………………………………………

No. …………………………………………..……….. Valid until …………………….……

*
21. Current occupation:

*
22. Employer and employer’s address and telephone number. For students, name and
address of educational establishment:

23. Purpose(s) of the journey:

□ Tourism □ Business □ 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 26. Member State of first entry:
other Member States of destination, if
ITALY
applicable): ITALY

27. Number of entries requested:

□ 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:

□ 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):

Address and e-mail address of inviting Telephone no.:

person(s)/hotel(s)/temporary accommodation(s):

*
31. Name and address of inviting company/organisation:

Surname, first name, address, telephone no., Telephone no. of

and e-mail address of contact person in company/organisation:
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), please specify:
□ referred to in field 30 or 31
□ other (please specify):

……….…………………………………………
Means of support:
Means of support:
□ Cash
□ Traveller’s cheques □ Cash
□ Credit card □ Accommodation provided
□ Pre-paid accommodation □ All expenses covered during the stay
□ Pre-paid transport □ Pre-paid transport
□ Other (please specify): □ 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 (for Italy the Ministry of Interior and the Police
authority) and to Europol for the purpose of the prevention, detection and investigation of terrorist offences and of
other serious criminal offences. The Ministry of Foreign Affairs and International Cooperation – MAECI (Piazzale della
Farnesina 1, 00135 Roma) www.esteri.it tel. 0039 06 36911 (switchboard), through the Diplomatic Representation
or Consulate where the visa application has been lodged, is the authority responsible for processing the data.

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 (for the Diplomatic Representations or Consulates please visit www.esteri.it e
http://vistoperitalia.esteri.it) 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 Italian national supervisory competent authority on the protection of personal
data is the MAECI Data Protection Officer / DPO (email: [email protected], certified email: [email protected]) or the
Italian Data Protection Authority (Piazza Venezia 11, 00187 ROMA; tel. 0039 06 696771 (switchboard); email:
[email protected]; pec: [email protected]).

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 (for minors, signature of parental

authority/legal guardian):