System Zdalnej Rejestracji https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...

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e-Konsulat
Home page > New Delhi > Visa > National Visa - Fill in form > Registration of visa application

This template will allow for the filling out and printing of your visa
application only. To make an appointment in a selected Consular
office, you are required to register your visa application.
Visa
National Visa -
form
Register
Application for national visa
National Visa - Fill in form
Fields No: 1, 2, 3, 5, 11, 13, 16, 31, 34 should be filled in by using the Latin alphabet letters only (A, B, C,
Schengen Visa - Register D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z). Any erroneous entry shall make the
form application void.
Schengen Visa - Fill in form
Personal data
1. Surname (s) (family name(s))
Visits
Legal matters 2. Surname (s) at birth (previously used surname (s))
Cancel appointment
3. First name(s)

4. Date of birth (year-month-day)

5. Place of birth

6. Country of birth

7. Current nationality/ies

Original nationality (nationality at birth)

8. Sex 9. Martial status

Male Single
Female Married
Separated
Divorced
Widow(er)
Other

National identity number

Passport data
12. Type of travel document
Ordinary passport
Diplomatic passport
Service passport
Official passport
Special passport
Other travel document (please specify):

13. Number of travel document

14. Date of issue (year-month-day) 15. Valid until (year-month-day)

16. Issued by

10.In the case of minors: Surname, first name, address (if different from applicants)
and nationality of parental authority/legal guardian
does not apply

Nationality

First name

Surname

Country

State/province

Place

Postal code

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Address

17. Applicants home address and e-mail address

Country

State/province

Place

Postal code

Address

Current email
Email address. Other e-mail addresses than the one provided in the VISA Application
Form shall not be used when contacting an applicant.
Phone area code

Phone number

18. Residence in a country other than the country of current nationality

No
Yes. Residence permit or equivalent

Number
Expiry date indefinitely

* 19. Current occupation

* 20. Employer and employers address and phone number. For students, name and address of school

Employer
School
State

State/province

Place

Postal code

Address

Phone area code

Phone

Name

Email

Fax area code

Number of fax

21. Main purpose(s) of the journey:

Tourism

Business

Visit to family or friends

Cultural

Sports

Official visit

Medical reason

Study

Other (please specify):

Details regarding travel arrangements.

22. Destination country 23. Member State of first entry

24. Number of entries requested 25. Duration of stay:

Single entry Visa requested for days (>90)

Two entries
Multiple entries

29. Intended date of arrival to the Republic of 30. Intended date of departure from the Republic of
Poland (year-month-day) Poland (year-month-day)

The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent
ascendant) while exercising their right to free movement. Family members of EU, EEA or CH citizens shall present
documents to prove this relationship and fill in fields No 34 and 35.

26. National visas issued during the past five years

No
Yes. Date(s) of validity

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from (year-month-day): to (year-month-day):

27. Fingerprints collected previously for the purpose of applying for a Schengen visa

No
Yes

28. Entry permit for the final country of destination, where applicable
does not apply

Data of receiving person

* 31, 32. Surname and first name of the inviting person(s) in the the Republic of
Poland. If not applicable, name of hotel(s) or temporary accommodation(s) in the
the Republic of Poland.

Person
Type
Company

Name

First name

Surname

Country

Place

Postal code

Phone area code

Phone number

Fax area code

Number of fax

Address

House number

Flat number

E-mail address

Data of person covering expenses

* 33. Cost of travelling and living during the applicants stay is covered
by the applicant himself/herself
By a sponsor (host, company, organisation), please specify
referred to in field 31 or 32
other (please specify)

Means of support during your stay

Cash
Travellers cheques
Credit cards
Accommodation
Prepaid transport
All expenses covered during the stay
Other:

Travel and/or health insurance. Valid until:

EU citizen data
34. Personal data of the EU or EEA citizen you depend on. This question should be answered only by family
members of EU or EEA citizens.

does not apply

Surname First name

Date of birth Number of passport

Nationality

spouse
child
Relationship:
grandchild
dependent ascendant

Applicant's data
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 (cf. Field No 24): 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 declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware
that the submission of an application and/or supplementary documents containing untrue personal data or false
information, declaration of untruth or the suppression of truth, forgery or tampering with a document with the intent
of passing it off as genuine or the use of such a document as genuine will lead to my application being rejected or to
the annulment of a national visa already granted, and may also render me liable to prosecution under Polish law. I
undertake to leave the territory of the Republic of Poland not later than the last day of the national visas validity. I
am aware that possession of a visa is only one of the prerequisites for entry into the territory of the Republic of
Poland. The 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 the Law on Aliens and am refused entry. The prerequisites for entry will be

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checked again on entry into the territory of the Republic of Poland. I am aware that a granted national visa may be
revoked if I no longer meet the requirement for its issuance.

* Questions marked with * may be omitted by family members of EU or EEA citizens (spouse, child, or dependent
ascendant). Family members of EU or EEA citizens have to present documents proving this relationship.

Please make sure that the data entered in the Visa Application Form are correct and press SAVE button to confirm it.
Press CORRECT button if you need to amend any data you have entered in the Application Form. Any erroneous
entry shall make the application void.

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