"Operator de date cu caracter personal notificat sub numarul 5285"

Solicitare de viza Application for Visa

Formular gratuit/This appli(~ation form is free

TIP DEVIZA: Ai Bi C 1. Numele/Surname(s) (familyname(s))

FOR EMBASSY / CONSULATE USE ONLY

2. NumelelanaStere/Slirname(s) birth (earlier family name(s at Data solicitarii :
3. Prenume/First names (given names)

4. Data nasterii/Date birth (day-month-year) of 6. Locul sitara nasteriil Placeand country of birth

5. CNP/lD-nnmber

Document procesat de :

Documente 0 Pasaport

doveditoare: vaJabil

7. Cetatenia

prezenta/Cnrrent

nationality/ies

8. Cetatenia

la nastere/Original

nationality

(nationality

at birth)

9. Sexul/Sex

110. Statut civil/Marital

status .f.~.l 0
d 0

0 Mijloace flnanciare f.J Invitatie [::1 Mijloace de transport Bilet de calatorie [,.;1 Asigurare?e S~tate r...1 Dovada as1guran1
de cazare

OBarbatesc/Male

0 Femeiesc/Fernale

i0 ,
0

CelibatarlSingle

Casaiont/Manied
.conditiilor

SeparntlSeparate

D1vortatlDiVorced

I 0

E Jtcep ti "1: (se va conp /.eta de do(umentele

infanctie

Vaduv(a)/Widow(er)O

Altele/Other

vrezentate de solicitan~ in conformitate ca art.40 din

11. NumeletataluilFather'sname

12. NumelemameiMother'sname

O. UC. 194/2002))

13. Document calatorierrypeof passport: de OPasaport diplomatic/Diplomatic passport OPasaport turistic:JNational passport 0 Pasaportde serviciu/Service passport 0 Document calatorie de pentru refugiatifTraye1 document (1951Cony.)

OPasaport pentru straini/Alien's passport OCarnet de marinar/Searnan's passport

OAltele (specificati)/Other traveldocument (please specify):

14.Nr. de pasaport/Number passport of

15. Emis de/Issued by

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

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

18. Daca aveti domiciliul in sIt stat decat cel de origine, va este permis sa va reintoarceti in acest stat/If you reside in a country other than your country of origin, have you permission to return to that country?

0 Nu/No

0 Da (nmnaml valabilitatea si pemlis itmii)N es,(number and

validi~~

19. Fuuctiaocupatain prezent/Current occupation

:.,=.,.,

=c'."
Viza

20. A11gajatorul, adresaacestuia nr. detel. Pentru elevisi studenti,denumireasi adresainstitutiei de si rnvatamant/Employer employer'saddress and and telephone number. For students, nameand addressof school

d Acordata
Tipul de viza :

21. Destinatia principala/Main destination1 22. Tipul de viza/fype of Visa:

0 Tranzitaeroporwar/Airpon ttan.'!it

0 TranzitJTransit 0 Scurta sedere/ shortstay

'8~ r::.1 c
Nr.deintrari:

[ 14. Nr. de intrari soJicitate/No. entriesrequested 25.DuratasederiilDuration of stay of 0 Unicaintrare/Single entry 0 Doua intrari/fwo entries Viza solicitata pt.Nisa is requested for: 0 Multipleintrari/Multiple entries
26:: Alte vize emise in ultimii 3 ani si valabi~r/Othervisas validity.

zile/days

D1[J2[J
Valabilade1a
La

Multiple

(issued during the past three years) and their period of

27.In cazul uneiv~iranzit, detineti permisiunea de a calatori in statui de destinatie/ln the case of transit, have you an entry permit for the final country of destination?

0 Nu/No

0 Da,valabiIa pam IaNes , validuntil:

Ernisa de /Issuing authority:

28. Sederianterioarein Romania/Previous staysin Romania

first entry or transit route

34.Dennmirea firmei romane de contact si a persoanei responsabile i n cadrnl acesteia. absenta, denumirea hotelului san adresa temporara in Romania! Name of host or company in Romania and contact person in host company.lfnot applicable, give name of hotel or temporary address in Romania.

Adresacompleta/FuIl address

e-maiJ/e-mail address

35. Cine suporta

cheltuielile o. 0.0.

de deplasare

si de sedere in Romania/Who

is payIng for your cost of travelling

and for your

I 0 Subsemnatul/Myself stay? costs oflivillg during your

0 Persoana fizica rornanalHost person(s)

0 Persoanajuridica romana(numiti cine si anexatidocumentedoveditoare)/Hostcompany. (Statewho and how and presentcorrespondingdocumentation):

0 Cartide credit/Credit cards Valid until:

37. Numele sotului(sotiei)/Spouse's family name 39. Prenumele sotului(sotiei)/ Spouse's name first 38. Numelela nastereal sotului(sotiei)/Spouse's family nameat birth

40.Datade nastere sot a 41. Locul denastereal sotului(sotiei)/ Spouse's dateof birth (day-month-year) Spouse's placeof birth

44. Dae a aveti alte rude in Romania?/lf

you have any relatives in Romania?

45. Am luat la cunostintaumlatoarele: toatedatele personate privire la subsernnatul(a) cu care apar in prezentul fonnular vor fi vuse la dispozitia autoritatilor romane competentesi procesatede catreacestea, dupa caz, in scopul luarii unci decizii cu privire la : prezentasolicitare de viza. Aceste date pot fi introduse si stocatein bazele de date accesibile autoritatilor romane competente. I Unnare solicitarii expresea subsernnatului,autoritatile consularemenite sa procesezeprezentasolicitare ma vor infOTml cu vrivire la rnodalitatea in care imi pot exercita dreptul de a veri fica datelepersonalefumizate, de a dispune rnodificarea sau indepartarealor, dacase dovedescincorecte, in conformitate cu prevederile legislatiei in vigoare in Romania. Declar ca, dupa stimta mea, toate datele fumizate sunt corecte si complete. Declar ca am cunostinta de faptul ca orice date false furnizate conduc la respingereaprezentei solicitari sau la anulareavizei emise in baza acestorasi pot duce la declansareaurnlaTirii mele penale in conformitate cu legearomana. Ma oblig sa parasescteritoriul Romaniei la expirareavizei ce mi-a fost acordata. Am fost infOTmlt ca detinereavizei nu reprezintadecat una dintre conditiile de indeplinit pentru intrarea in Romania. Simpla eliberare a vizei nu Dresupunefaptul ca sunt indreptatit(a) la primirea unor compensatii daca nu indeplinesc conditiile prevazutela Capitolul I I (Dispozitii generale privind intrarea, sederea iesireastrainilor) al OUG 194/2002si imi esterefuzataintrarea in Romania. si Indeplinirea conditiilor de intrare va fi supusaverificarii la rnomentul intrarii pe teritoriul Romaniei.// I am awareof and consentto the following: any personal dataconcerningme which appearon this visa application fonn will be supplied to the relevant authorities in Romania and processedby thoseauthorities, if necessary,for the purposesof a decision on my visa application. Such datamay be input into, and storedin, databases accessibleto the relevant authorities in Romania. At my expressrequest,the consular authority processingmy application will inform me of the manner in which I may exercise my right to check the personal dataconcerning me and have them altered or deleted, in particular, should they be inaccurate, in I accordancewith the national law of the stateconcerned. 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 rejectedor 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. 1 have beeninformed that possessionof a visa is only one of the prerequisites for entry into the Europeanterritory of the Schengenstates.The mere fact that a visa has been ~ted to me doesnot mean that 1 will be entitled to compensationif I fail to comply with the relevant provisions of Chapter I 1 (General provisions regarding entry, stay and exit of aliens) ofGEO no. 194/2002and am thus refusedentry. The prerequisitesfor entry will be checkedagain on entry into the territory of Romania.

46. Adresa de domiciliu a solicitantului/Applicant's home address

47. Nr.detelJPhone no.

48. Data la (locul si data)/Placeand date (day-monthyear)

~'untde accord cupre/ucrarea date/orprezentate in conformitate Legea677/2001 cu (1 agreewith theprocessing ofdatapresentedin accordingwith Law no. 677/2001) (Je suisd 'accordavec /e traitementdesdonnespresentees conformement Loi no. 677/2001) a/a 49. Semnatura (pentru minori, semnatura
reprezentantului legal)/Signature signature of custodian/guardian) (for minors,