ANEXA 9

Operator de date cu caracter personal notificat sub numarul 5285

Formular de cerere pentru viz de lung edere

TAMPILA AMBASADEI/CONSULATULUI
FOTOGRAFIE
3/4

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 /

POPESCU
2.

CONSULATE USE
ONLY

Numele la natere/ Surname(s) at birth (earlier family name(s)) /

TURCANU
Data solicitrii :

3.

Prenume/First names (given names) /

TATIANA
4.

Document procesat de :

5. CNP/ ID-number

Data naterii/Date of birth (day-month-year) /

28.07.1979
6. Locul i ara naterii/ Place and country of birth /

Documente doveditoare:

SAT PUHOI, IALOVENI, REPUBLICA MOLDOVA

7. Cetenia prezent/Current nationality/ies /

8. Cetenia la natere/Original nationality (nationality at birth) /

MOLDOVENEASCA

MOLDOVENEASCA

9.

10.

Sexul/Sex /

Brbtesc/Male/

Mijloace financiare

Statut civil/Marital status / :

Celibatar/Single//

Cstorit/Married//

Femeiesc/Female/

Separat/Separated/

Divorat/Divorced/ ()

Altele/Other/

12. Prenumele mamei/Mothers name /

VASILE

MARIA

Paaport turistic/National passport / .

Paaport pentru strini/Aliens passport /

Carnet de marinar/Seamans passport /
Altele (specificai)/Other travel document (please specify): / ..............

B1234

15. Emis de/Issued by/

...............................................
Nr./data aviz de
angajare in munca

...............................................
Nr./data aviz MAI
pentru reintregirea familiei

Document de cltorie pentru refugiai/Travel document (1951 Conv.) /

Nr./data aviz ARIS

...............................................
Nr./data aviz Ministerul
Culturii si Cultelor

13. Document de cltorie/Type of passport/ :

14. Nr. de paaport/Number of passport/

Invitaie
Mijloace de transport
Bilet de calatorie
Asigurare de sntate
Dovada asigurarii
conditiilor de cazare

...............................................
Nr./data aviz de studii

Vduv()/Widow(er)/ (- /-)

11. Prenumele tatlui/Fathers name /

Paaport valabil

REPUBLICA MOLDOVA

...............................................
Nr./data aviz MAI pentru alte
scopuri
...............................................

16. Data emiterii/Date of issue (d/m/y)/

27.02.2020

27.02.2010
18.

17. Valabil pn la/Valid until (d/m/y) /

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)/ (

) ...

19.

Funcia ocupat n prezent/ Current occupation/

PROFESOR
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

LICEUL VASILE ALECSANDRI CHISINAU

21. Destinaia principal/Main destination /

BUCURESTI
22.

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

Tipul de viz :
D

23.

Durata ederii/ Duration of stay /

Nr. de intrri:
1
2

Multiple

Unic intrare/Single entry/

Dou intrri/Two entries/
Multiple intrri/Multiple entries/

24.

Viza solicitat pt./Visa is requested for: 90.. zile/days/

........................ requested for: ..
zile/days

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

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

NU ESTE CAZUL

25. ederi anterioare n Romnia/Previous stays in Romania/

NU ESTE CAZUL

26. Scopul ederii n Romnia/Purpose of travel /

Activiti economice (D/AE)/ Economic activities /

Rentregirea familiei (D/VF)/Family reunification / ,
Activiti profesionale (D/AP)/Professional activities /
Cercetare tiinific (CS) / Scientific Research/
Activiti comerciale (D/AC)/ Commercial activities /
Angajare n munc (D/AM)/Work contract /
Studii (D/SD)/Studies /
Activiti religioase sau umanitare/Religious activities /
Alte activiti (D/AS)/Other activities /

FOR EMBASSY / CONSULATE

USE ONLY

27.

28.

Data sosirii/ Date of arrival (day-month-year)/

20.10.2010
29.

19.01.2011

Punctul de intrare, sau traseul de tranzit/Border of first entry or 30. Mijloc de transport/Means of transport/
transit route/

AUTOTURISM

ALBITA
31.

Data plecrii/Date of departure (day-month-year)

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/

Tel. i fax/phone and fax

no./.

POPESCU MARIAN

0040123456789

Adresa complet/Full address/

e-mail/e-mail address/

BUCURESTI, BLVD. DACIA NR. 17

32.

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)/ :(
) : .....................................................................................................................................................................................................
.....................................................................................................................................................................................................................
33. Modaliti de ntreinere n Romnia/Means of support during your stay /
Cash/
Cri de credit/Credit cards/

Cecuri de cltorie/Travellers' cheques/

Cazare pltit/Accommodation /

Altele/Other:
Asigurare medical valabil pn la/Travel and/or health insurance. Valid until: ,
......................................................................................................................................

34.

35. Numele la natere al soului(soiei)/ Spouses family

Numele soului(soiei)/Spouses family name/

/

name at birth /
/

POPESCU
36.

POPESCU

Prenumele soului(soiei)/ Spouses first

name /
/

Data de natere a soului (soiei)/

Spouses date of birth (d/m/y) /
/

14.07.1975

MARIAN
39.

37.

38.

Locul de natere al soului(soiei)/

Spouses place of birth /

/

BUCURESTI

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 /

1 ................................................NU

Data naterii/Date of birth /

ESTE CAZUL..........................................................................................................

2 .............................................................................................................................................................................................................
3 .............................................................................................................................................................................................................

40.

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/

MARIAN

POPESCU
Nr. de paaport/Number of passport/

XT123456
Legtura familial/Family relationship/ :

SOT
41. Daca aveti alte rude in Romania?/If you have any relatives in Romania?/

NU
42.

Date cu caracter personal prelucrate n conformitate cu dispoziiile Legii nr. 677/2001. Acest document este destinat numai pentru uzul instituiilor
abilitate de lege i nu poate fi dat publicitii. Operaiunile exercitate fr drept de legtur cu acest document (multiplicarea, difuzarea, adaptarea,
completarea, extragerea, utilizarea, dezvluirea) ctre teri prin transmiterea sub orice form, sunt pedepsite de legea romn i intr sub incidena Legii nr.
677/2001.
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.
Sunt de accord cu prelucrarea datelor prezentate n conformitate cu Legea nr. 677/2001.
Personal data, processed according to the provisions of Law no. 677/2001. The presented document is destined to the exclusive use of the institutions with
competences attributed by law and cannot be made public. All types of unauthorized operations in relation to this document (such as its multiplication,
distribution, adaptation, completion, data extraction, use, public display ), with a view to its distribution towards third parties concerned, will be pushined bz
Romanian law and will be subject to Law no. 677/2001.
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.
I agree with processing of data presented in according with Law no. 677/2001.
. 677/2001.
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, 677/2001.

43. Adresa de domiciliu a solicitantului/Applicants home address/

CHISINAU, STRADA VALERIU ENESCU 19/1

45.

Dat la (locul i data)/Place and date (d/m/y)/ (

)

CHISINAU, 15.09.2010

44. Nr.de tel./Phone

no./ .
012345678

46. Semntura (pentru minori, semntura reprezentantului

legal)/Signature (for minors, signature of custodian/guardian) /
( ,
)