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FOTOGRAFIE 3/4

TAMPILA AMBASADEI/CONSULATULUI

Operator de date cu caracter personal notificat sub numrul 5285

Solicitare de viz Application for Visa


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-monthyear) 5. CNP/ ID-number

Document procesat de :

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 Cstorit/Married Separat/Separated Divorat/Divorced Vduv()/Widow(er) Altele/Other 12. Numele mamei/Mothers name

Brbtesc/Male Femeiesc/Female
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

15. Emis de/Issued by

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................. ..... ................................... ...........

16. Data emiterii/Date of issue (daymonth-year)

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 (number and validity)

Da (numrul i valabilitatea permisiunii)/Yes,

......................................................................................................................................................... 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.

Viza : Refuzat Acordat

21. Destinaia principal/Main destination

Tipul de viz : D

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

25.Durata ederii/ Duration of stay

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

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

Nr. de intrri: 1 2 Multiple

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 Rentregirea familiei (D/VF)/Family FOR EMBASSY / CONSULATE USE reunification Activiti profesionale (D/AP)/Professional activities Straini, membrii de familie ai cetatenilor romani (D/CR)/ Activiti comerciale (D/AC)/ Commercial activities Members of romanian family Angajare n munc (D/AM)/Work contract Alte activiti (D/AS)/Other activities Activiti religioase sau umanitare/Religious activities Studii (D/SD)/Studies ............................................................................................................................................... .................................................................
29. Data sosirii/ Date of arrival (day-monthyear) 31. Punctul de intrare/Border of first entry 30. Data plecrii/Date of departure (daymonth-year) 32. Mijloc de transport/Means of transport

ONLY

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 Cri de credit/Credit cards Cazare pltit/Accommodation Altele/Other: Asigurare medical valabil pn la/Travel and/or health insurance. Valid until: .............................................................................................................................
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 Prenume/First 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? 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 47. Dat la (locul i data)/Place and date (day-month-year)

46. Nr.de tel./Phone no.

48. Semntura (pentru minori, semntura reprezentantului legal)/Signature (for minors, signature of custodian/guardian)