TAMPILA

AMBASADEI/CONSULATULUI

FOTOGRAFIE
3/4

Solicitare de viz
Application for Visa
TIP DE VIZA: A; B; C
Numele/Surname(s) (family name(s) /():

FOR EMBASSY /
CONSULATE USE
ONLY

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

() ():
3. Prenume/ First names (given names)/ :
4. Data naterii/Date of birth (day-month-year)/
5. CNP/ ID-number /
( --):
:
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 /
Brbtesc/Male/
Femeiesc/Female/

10. Statut civil/Marital status/ :

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

11. Numele tatlui/Fathers name/ ,

13. Document de cltorie/ Type of passport/ :

Diplomatic/Diplomatic passport

Paaport de serviciu/Service passport

Paaport pentru strini/Aliens passport

Paaport turistic/National passport

Document de cltorie pentru refugiai/Travel document (1951 Conv.)
( 1951 .)
Carnet de marinar/Seamans passport

Altele (specificai)/Other travel document (please specify)/ :

..................................................................................................................................................................................................................
........................
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)

: (,,): .

Data solicitrii :

Document procesat de :
Documente doveditoare:
Paaport valabil
Mijloace
financiare
Invitaie
Mijloace de transport
Bilet de calatorie
Asigurare de sntate
Dovada asigurarii
conditiilor de cazare
Exceptii: (se va completa
in functie de documentele
prezentate de solicitant, in
conformitate cu art.40 din
O.U.G.194/2002))

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 /
Da (numrul i valabilitatea permisiunii)/Yes, (number and validity)
.
( ) .
...............................................................................................................................................................................................................
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/

,
:

22. Tipul de viz/Type of Visa /

23. Viz/Visa /
:
Individual/Individual
Tranzit aeroportuar/Airport transit

-
Colectiv/Collective
.
Tranzit/Transit /

Scurta sedere/ short stay

24. Nr. de intrri solicitate /No.of entries requested
25.Durata ederii/ Duration of stay / :

Unic intrare/Single entry/
Viza solicitat pt./Visa is requested for: .. zile/days
Dou intrri/Two entries /
.
Multiple intrri/Multiple entries/

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

Tipul de viz :
A
B
C
Nr. de intrri:
1
2

Multiple

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

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/Previous stays in Romania/ :

29. Scopul ederii n Romnia/Purpose of travel/ :

FOR EMBASSY /
Misiune (C/M)/Official /

Afaceri (C/A)/Business /

Transport (C/TR)/ Transportation)/

Turism (C/TU)/Tourism/

Vizit (C/VV)/Visit to Family or Friends/

Activiti sportive (C/SP) /Sport/ .

Activiti culturale, tiinifice, umanitare, tratament medical de scurta durata care nu contravin legilor romne (C/ZA),
alte activitii/ , , ,
, (/ZA) / .

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

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

CONSULATE USE ONLY

 (, , ):
(, , ):
.
.
32. Punctul de intrare, sau traseul de tranzit/Border of first
33. Mijloc de transport/Means of transport/
entry or transit route/
:
:
. .
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./ ,
. : .

Nume/Name/ : .. Tel.i fax/phone and fax no./

. :
.. .
Adresa complet/Full address/ : .. e-mail/e-mail address/
.. :
.. ..
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?/ :
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/ :
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/ /
. ................................................................................................................................................
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.//
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.
46. Adresa de domiciliu a solicitantului/Applicants home address/
47. Nr.de tel./Phone
:
no./ .:
.
48. Dat la (locul i data)/Place and date (day-monthyear) / :
(--):
..

49. Semntura (pentru minori, semntura reprezentantului

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

..