FOTOGRAFIE 3/4

Operator de date cu caracter personal, notificat sub numrul 5285

TAMPILA AMBASADEI/CONSULATULUI

Solicitare de viz Visa application form

Formular gratuit / This application form is free
TIP DE VIZA: D 1. Numele/Surname(s) (family name(s))

FOR EMBASSY /
CONSULATE USE ONLY

2. Numele la natere/ Surname(s) at birth (earlier family name(s)) Data solicitrii : 3. Prenume/First names (given names) 4. Data naterii/Date of birth (day-month-year) 6. Locul i ara naterii/ Place and country of birth 7. Cetenia prezent/Current nationality/ies 9. Sexul/Sex 8. Cetenia la natere/Original nationality (nationality at birth) 10. Statut civil/Marital status : Celibatar/Single Separat/Separated Vduv()/Widow(er) 12. Numele mamei/Mothers name Documente doveditoare: Paaport valabil Mijloace financiare Invitaie Mijloace de transport Bilet de calatorie Asigurare de sntate Dovada asigurarii conditiilor de cazare Nr./data aviz ARIS ............................................... Nr./data aviz de studii ................................................... Nr./data aviz de angajare in munca................... ................................................... Nr./data aviz Ministerul Culturii si Cultelor.................................... Nr./data aviz MAI pentru reintregirea familiei Nr./data aviz MAI pentru alte scopuri................. ................................................... 5. CNP/ ID-number Document procesat de :

Brbtesc/Male

Femeiesc/Female

Divorat/Divorced Altele/Other

Cstorit/Married

11. Numele tatlui/Fathers name

13. Document de cltorie/Type of passport:

Paaport turistic/National passport Document de cltorie pentru refugiai/Travel document (1951 Conv.) Paaport pentru strini/Aliens passport Carnet de marinar/Seamans passport

Altele (specificai)/Other travel document (please specify):

14. Nr. de paaport/Number of passport 16. Data emiterii/Date of issue (day-month-year) 15. Emis de/Issued by 17. Valabil pn la/Valid until (day-month-year)

18. Dac avei domiciliul n alt stat dect cel de origine, v este permis s v rentoarcei n acest stat/If you reside in a country other than your country of origin, have you permission to return to that country?

Nu/No

Da (numrul i valabilitatea permisiunii)/Yes, (number and validity)

Viza : Refuzat Acordat

......................................................................................................................................................... 19. Funcia ocupat n prezent/ Current occupation 20. Angajatorul, adresa acestuia i nr. de tel. Pentru elevi i studeni, denumirea i adresa instituiei de nvmnt/Employer and employers address and telephone number. For students, name and address of school.

21. Destinaia principal/Main destination

Tipul de viz : D

24. Nr. de intrri solicitate/No. of entries requested

Unic intrare/Single entry Dou intrri/Two entries Multiple intrri/Multiple entries

25.Durata ederii/ Duration of stay

Nr. de intrri: 1 2

Multiple

Viza solicitat pt./Visa is requested for: .. zile/days

26. Alte vize emise n ultimii 3 ani i valabilitatea lor/Other visas (issued during the past three years) and their period of validity.

Valabil de la ................................................... La ...................................................

27. ederi anterioare n Romnia/Previous stays in Romania

28. Scopul ederii n Romnia/Purpose of travel

Activiti economice (D/AE)/ Economic activities Activiti profesionale (D/AP)/Professional activities Activiti comerciale (D/AC)/ Commercial activities Angajare n munc (D/AM)/Employment Detaare (D/DT) / Secondment Activiti religioase (D/AR)/Religious activities

Rentregirea familiei (D/VF)/Family reunification Alte activiti (D/AS)/Other activities Studii (D/SD)/Studies Activiti de cercetare tiinific (D/CS) / Research

FOR EMBASSY /
CONSULATE USE ONLY

................................................................................................................................................................................................................
29. Data sosirii/ Date of arrival (day-month-year) 31. Punctul de intrare/Border of first entry 30. Data plecrii/Date of departure (day-month-year) 32. Mijloc de transport/Means of transport

33.Denumirea firmei romne de contact i a persoanei responsabile n cadrul acesteia. n absen, denumirea hotelului sau adresa temporar n Romnia/ Name of host or company in Romania and contact person in host company. If not applicable, give name of hotel or temporary address in Romania. Nume/Name Adresa complet/Full address Tel. i fax/phone and fax no. e-mail/e-mail address

34. Cine suport cheltuielile de deplasare i de edere n Romnia/Who is paying for your cost of travelling and for your costs of living during your stay?

Subsemnatul/Myself Persoan fizic romn/Host person(s) Persoan juridic romn(numii cine i anexai documente doveditoare)/Host company. (State who and how and present corresponding documentation):

...................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................... 35. Modaliti de ntreinere n Romnia/Means of support during your stay Cash Cecuri de cltorie/Travellers' cheques Cazare pltit/Accommodation Altele/Other: Asigurare medical valabil pn la/Travel and/or health insurance. Valid until: ............................................................................................................................. Cri de credit/Credit cards

36. Numele soului(soiei)/Spouses family name 38. Prenumele soului(soiei)/ Spouses first name

37. Numele la natere al soului(soiei)/ Spouses family name at birth 40. Locul de natere al soului(soiei)/ Spouses place of birth

39.Data de natere a soului (soiei)/ Spouses date of birth (day-month-year)

41. Copii (se vor completa solicitri separate pentru cei care dein paaport individual)/Children (Applications must be submitted separately for each passport) Nume/Name Prenume/First name Data naterii/Date of birth

1 ....................................................................................................................................................................................................................................... 2 ....................................................................................................................................................................................................................................... 3 .......................................................................................................................................................................................................................................

42. Datele persoanale ale ceteanului romn n ntreinerea cruia v gsii. Rubric de completat doar de ctre cei aflai n ntreinerea unui cetean romn/Personal data of the Romanian citizen you depend on. This question should be answered only by family members of Romanian citizens.

Nume/Name Nr. de paaport/Number of passport Legtura familial/Family relationship : 43.Daca aveti alte rude in Romania?/If you have any relatives in Romania?

Prenume/First Name Data naterii/Date of Birth

44. Am luat la cunotin urmtoarele: toate datele personale cu privire la subsemnatul(a) care apar n prezentul formular vor fi puse la dispoziia autoritilor romne competente i procesate de ctre acestea, dup caz, n scopul lurii unei decizii cu privire la prezenta solicitare de viz. Aceste date pot fi introduse i stocate n bazele de date accesibile autoritilor romne competente. Urmare solicitrii exprese a subsemnatului, autoritile consulare menite s proceseze prezenta solicitare m vor informa cu privire la la modalitatea n care mi pot exercita dreptul de a verifica datele personale furnizate, de a dispune modificarea sau ndeprtarea lor, dac se dovedesc incorecte, n conformitate cu prevederile legislaiei n vigoare n Romnia. Declar c, dup tiina mea, toate datele furnizate sunt corecte i complete. Declar c am cunotin de faptul c orice date false furnizate conduc la respingerea prezentei solicitri sau la anularea vizei emise n baza acestora i pot duce la declanarea urmririi mele penale n conformitate cu legea romn. M oblig s prsesc teritoriul Romniei la expirarea vizei ce mi-a fost acordat. Am fost informat c deinerea vizei nu reprezint dect una dintre condiiile de ndeplinit pentru intrarea n Romnia. Simpla eliberare a vizei nu presupune faptul c sunt ndreptit() la primirea unor compensaii dac nu ndeplinesc condiiile prevzute la Capitolul II (Dispoziii generale privind intrarea, ederea i ieirea strinilor) al OUG 194/2002 i mi este refuzat intrarea n Romnia. ndeplinirea condiiilor de intrare va fi supus verificrii la momentul intrrii pe teritoriul Romniei.// I am aware of and consent to the following: any personal data concerning me which appear on this visa application form will be supplied to the relevant authorities in Romania and processed by those authorities, if necessary, for the purposes of a decision on my visa application. Such data may be input into, and stored in, databases accessible to the relevant authorities in Romania. At my express request, the consular authority processing 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 altered or deleted, in particular, should they be inaccurate, in 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 and may 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. I have been informed that possession of a visa is only one of the prerequisites for entry into the European territory of the Schengen 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 Chapter II (General provisions regarding entry, stay and exit of aliens) of GEO no.194/2002 and am thus refused entry. The prerequisites for entry will be checked again on entry into the territory of Romania. 45. Adresa de domiciliu a solicitantului/Applicants home address 46. Nr.de tel./Phone no. 47. Dat la (locul i data)/Place and date (day-monthyear) 48. Semntura (pentru minori, semntura reprezentantului legal)/Signature (for minors, signature of custodian/guardian)