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Operator de date cu caracter personal notificat sub numrul 5285

FOTOGRAFIE
3/4

Solicitare de viz
Application for Visa

TAMPILA
AMBASADEI/CONSULATULUI

Formular gratuit/This application form is free

TIP DE VIZA: DS

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)

5. CNP/ ID-number

Document procesat de :

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


7. Cetenia prezent/Current nationality/ies

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

9. Sexul/Sex

10. Statut civil/Marital status :


Celibatar/Single
Cstorit/Married
Separat/Separated
Divorat/Divorced
Vduv()/Widow(er)
Altele/Other

Brbtesc/Male

Femeiesc/Female

11. Prenumele tatlui/Fathers name

Documente doveditoare:

Paaport valabil

12. Prenumele mamei/Mothers name


Nota verbala

13. Document de cltorie/Type of passport:

Paaport diplomatic/Diplomatic passport


Paaport de serviciu/Service passport
14. Nr. de paaport/Number of passport

15. Emis de/Issued by

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

17. Valabil pn la/Valid until (day-month-year)

18 Funcia ocupat n prezent/ Current occupation


Viza :
Refuzat
Acordat
19. Nr. de intrri solicitate/No. of entries requested

Unic intrare/Single entry


Dou intrri/Two entries
Multiple intrri/Multiple entries

20.Durata ederii/ Duration of stay

Tipul de viz :
DS
Nr. de intrri:
1
2

Multiple

21. Indicati misiunea diplomatica sau oficiul consular din Romania /Indicate diplomatic mission or consular office from
Romania
Valabil de la
..............................................
.....
La
..............................................
.....

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

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


FOR EMBASSY /
CONSULATE USE ONLY

24. Punctul de intrare/Border of first entry

26. Numele soului(soiei)/Spouses family name


28. Prenumele soului(soiei)/
Spouses first name

25. Mijloc de transport/Means of transport

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


name at birth

29.Data de natere a soului (soiei)/


30. Locul de natere al soului(soiei)/
Spouses date of birth (day-month-year) Spouses place of birth

31. 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
.............................................................................................................................................................................................................
..........................
32. 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, copletarea, 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.//
Sunt de acord cu prelocrarea datelor preyentate in conformitate cu Legea 677/2001.
Personal data, processed according to the provisions of Law n 677/2001. The present 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 punished by Romanian law and will be subject to Law n

677/2001.
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.
I agree with processing of data presented in according with Law no. 677/2001
33. Adresa de domiciliu a solicitantului/Applicants home address
34. Nr.de tel./Phone no.
35. Dat la (locul i data)/Place and date (day-monthyear)

36. Semntura (pentru minori, semntura reprezentantului


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