Operator de date cu caracter personal notificat sub numrul 5285

FOTOGRAFIE
3/4 TAMPILA
AMBASADEI/CONSULATULUI

Solicitare de viz
Application for Visa
Formular gratuit/This application form is free
TIP DE VIZA: A; B; C

1. Numele/Surname(s) (family name(s))

FOR EMBASSY /
AMIRA
CONSULATE
USE ONLY
2. Numele la natere/ Surname(s) at birth (earlier family name(s))

Data solicitrii :
3. Prenume/First names (given names)
SIRINE
4. Data naterii/Date of birth (day-month-year) 5. CNP/ ID-number Document procesat de :
30-04-1992 09182291
6. Locul i ara naterii/ Place and country of birth
Documente doveditoare:
TUNIS - TUNISIA
7. Cetenia prezent/Current nationality/ies 8. Cetenia la natere/Original nationality (nationality at birth) Paaport valabil
TUNISIA TUNISIA
Mijloace financiare
9. Sexul/Sex 10. Statut civil/Marital status :
Brbtesc/Male X Femeiesc/Female X Celibatar/Single Cstorit/Married
Invitaie
Mijloace de transport
Bilet de calatorie
Separat/Separated Divorat/Divorced Asigurare de sntate
Dovada asigurarii
Vduv()/Widow(er) Altele/Other conditiilor de cazare
Exceptii: (se va completa
11. Prenumele tatlui/Fathers name 12. Prenumele mamei/Mothers name in functie de documentele
prezentate de solicitant, in
Abdelwahab Sihem conformitate cu art.40 din
O.U.G.194/2002))

13. Document de cltorie/Type of passport:

Paaport diplomatic/Diplomatic passport X Paaport turistic/National passport

Paaport de serviciu/Service 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
F396629 Tunisian Embassy - Abu Dhabi
16. Data emiterii/Date of issue (day-month-year) 17. Valabil pn la/Valid until (day-month-year)

12-11-2014 11-11-2019

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 X Da (numrul i valabilitatea permisiunii)/Yes, (number and
31\2016\20\001217 01-06-2018
validity) .........................................................................................................................................................
*19. Funcia ocupat n prezent/ Current occupation
Medical Intern Viza :
*20. Angajatorul, adresa acestuia i nr. de tel. Pentru elevi i studeni, denumirea i adresa instituiei de Refuzat
nvmnt/Employer and employers address and telephone number. For students, name and address of school. Acordat

21. Destinaia principal/Main destination 22. Tipul de viz/Type of Visa : 23. Viz/Visa : Tipul de viz :
Tranzit aeroportuar/Airport transit X Individual/Individual A
Bucharest Tranzit/Transit Colectiv/Collective B
X Scurta sedere/ short stay C

24. Nr. de intrri solicitate/No. of entries requested 25.Durata ederii/ Duration of stay
Nr. de intrri:
X Unic intrare/Single entry
Dou intrri/Two entries 20
Viza solicitat pt./Visa is requested for: .. zile/days
1 2 Multiple

Multiple intrri/Multiple entries Valabil de la

............................................
26. Alte vize emise n ultimii 3 ani i valabilitatea lor/Other visas (issued during the past three years) and their period of .......
validity. La
USA Visa 2014-2024 ............................................
.......
SCHENGEN VISA 07-2015 TO 08-2015

27. n cazul unei vize de tranzit, deinei permisiunea de a cltori n statul de destinaie/In the case of transit, have you
an entry permit for the final country of destination?
Nu/No Da, valabil pn la/Yes , valid until:
Emis de /Issuing authority:

*28. ederi anterioare n Romnia sau n alte State Schengen/Previous stays in Romania or other Scengen States

Germany 25-07-2015 to 23-08-2015

29. Scopul ederii n Romnia/Purpose of travel

FOR EMBASSY /
Misiune (C/M)/Official Afaceri (C/A)/Business CONSULATE USE ONLY

Transport (C/TR)/ Transportation) Turism (C/TU)/Tourism

Vizit (C/VV)/Visit to Family or Friends X Activiti culturale, tiinifice, umanitare, tratament medical
de scurta durata care nu contravin legilor romne (C/ZA)/
Activiti sportive (C/SP) /Sport Other activities

*30. Data sosirii/ Date of arrival (day-month-year) *31. Data plecrii/Date of departure (day-month-year)
18-08-2017 28-08-2017
*32. Punctul de intrare, sau traseul de tranzit/Border of *33. Mijloc de transport/Means of transport
first entry or transit route

Romania Airplane

*34.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.
Romanian Student Society of Surgery, Pisica Dana
Nume/Name Tel. i fax/phone and fax no.
Pisica Dana
40729341725
Adresa complet/Full address e-mail/e-mail address
No. 42 C.A. ROSETTI Street, Ap. Building A , Ap 6
presidente.bucuresti@sscr.ro
Sector 2, Bucharest
*35. 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?
X 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):

.........................................................................................................................................................................................
.............................
.............................................................................................................................................................................................................
.............................
*36. Modaliti de ntreinere n Romnia/Means of support during your stay
X Cash Cecuri de cltorie/Travellers' cheques X Cri de credit/Credit cards
X Cazare pltit/Accommodation Altele/Other:
Asigurare medical valabil pn la/Travel and/or health insurance. Valid until:
31-12-2017
.............................................................................................................................
37. Numele soului(soiei)/Spouses family name 38. Numele la natere al soului(soiei)/ Spouses family
name at birth

39. Prenumele soului(soiei)/ 40.Data de natere a soului (soiei)/ 41. Locul de natere al soului(soiei)/
Spouses first name Spouses date of birth (day-month-year) Spouses place of birth

42. 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
.............................................................................................................................................................................................................

43. 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 Data naterii/Date of

Birth

Legtura familial/Family relationship :

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

45. 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.
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
46. Adresa de domiciliu a solicitantului/Applicants home address 47. Nr.de tel./Phone no.
11 Rue de Carthage, Manouba Centre, Manouba, Tunisie 71 608 024

48. Dat la (locul i data)/Place and date (day-month- 49. Semntura (pentru minori, semntura reprezentantului
year) legal)/Signature (for minors, signature of
custodian/guardian)
Tunis, 27-07-2017

(*) Rubricile nsoite de (*) nu trebuie completate de membrii familiei resortisanilor UE sau SEE (so, soie, copil sau
ascendent dependent). Membrii familiei resortisanilor UE sau SEE trebuie s prezinte documentele care dovedesc relaia de
rudenie.
(*) The questions marked with * do not have to be answered by family members of EU or EEA citizens (spouse, child or
dependent ascendant). Family members of EU or EEA citizens have to present documents to prove this relationship.