ry Harmonised application form / Formulaire harmonisé de demande ‘Application for Schengen Visa /Demande de visa Schengen, This application form is free / Ce formulaire est gratuit Fields 1-3 shall be filed in in accordance with the data i the travel document Les données des cases 183 doWvent carespandro 8 celles fgurant su le decumont de voyage, ‘Surname (Family name): / Nor Irom ae fam: ‘Sumame at bith (Forma family ames): "Nome nalssanco (noms) do fame antesout} First name(s) Given name(s 7 3. ranomis) Noms) usue) Date of birth (day month yer (5 Place of bith: 4 Date de naseance(jourmas- leu do nassance: 8. Pays denaissance: Curent nationality: Nationaité actu: 7 Nationality at bith (i aitferent: (Other nationals: National la rassance, si ‘Autres nana) siren: 2: [sax: oe: 2 Male/= Masouln © Female (= Féminin 3 Single /Célbalaie —o Maried/ Maree) 1 Registered parinrship /Parenarat enegstré | eacae 2 Separated / Séparé(e) > Divorced / Divorce 5 Widower Vou (vouve) 5 Other (please speciy):/ Autre (a presen Parental authority (in ease of minors) egal guardian (surname, frst name, adaess, if diferent from applicant’, telephone no., ‘email address, and nationality: Avon paentle (pour les mineurs)uteur egal (nom, prénom, adresse (arene de cote du ‘demandeun, numero de telephone, aaresse eecronque et national) 10. National identity number, where 11, Applicable: Numéro national ident, le cas éencan: ‘Type of travel document: /Type de > Ordinary passport / Passepot onal = Diplomatic passport Passeport diplomas document de voyage: = Service passport /Passepor de servce > Ocal passport! Passepor oft 2 5 Special passport /Passepon spect 3 Other travel document (please specify. /Aute document de voyage (8 prise ‘Number of travel document: Numéro du document de voyage "4. Date of issue: Data do devancs: 13 ‘Valid unt: Date exertion 18. ssued by (country: /DBiws par pa) 6 Family members of EU, EEA or CH etizans shal not ili fields no. 24,22, 30,31 and 32 (marked with)! Les membres de a fail (es ctoyens de TUE, de TEEE ou du CH ne dowent pas remplrles champs no. 21,22, 30,31 et 32 (marqués dun“) Personal data ofthe family member whois an EU, EEA or CH citizen if applicable: / Données porsonnolls du membre de a fami qui est ressorissant de TUE, de TEEE ou de Is Conteraton suisse, tas én ‘Surname (family name: Nom (oom ‘de fami) First name(s): /Prénomis) Nomis) sue) Date of birth (day month year Dato de nassance (eurals-anne): Nationaiy: National ‘Number of travel document or card: Numéro du document de ‘voyage ou de a cae dientte FoR OFFICAL USE ONLY ste of apaiation: ppleaton number Appleton eda: embassy / Consulate Service provide! © Commer Intermediary < Border (Noel Fle handed by Supporting documents 2rTrawl document Means of vsstance Means of wansort 3 Other Via decor: efaes 3c Number of entries SimtileFamily relationship with an EU, EEAOr CH citizen applicable: 5 Spouse / Conjoint o Child / Enfant o Grandchild /Peti-fs ou pel en le pareté avec un ressotssent Dependent ascendant Ascendant & charge 18 detUE, de TEEE ou dela , 2 Registered Partnership Partenarit enegiste Contain suis, le cas écéan: > Reaistered Pa ‘Applicant's home address and mall address: /haresse du domicile ct adresse électronique du 1. domandeur Telephone m0. 7 de lphone Residence in a country other than ‘the country of current nationality: / 2 No/ No Fésdonce dans un pays aure que 3 Yes. Residence permit or equivalent clu dela atonal atu: ‘Ou, Aulorsaion de séou ou equivalent Number N° val until Date expaton ‘Current occupation: / +21, Profession actuele Employer and employer's address and telephone number, For students, name and address of educational establishment: / "Nom, aresse et numére de teépnone de femployeur Pou les Gtusians, adresse de etablssementeenseignemont “2, urpose(s of the jourey:/ Cb) Tourism /Toursme > Business /Afaes ‘du voyape: 5 Visiting family or fends / Viste ala fame ou des amis _o Cukural Cutwre 2 5 Spon ‘Spors > Ofial visit iste oficete = Medical reasons / Rasons médicales 2 Study / Etudes 5 Alport transit Trans aéroporuare > Other Autre (please speiy a presen} ‘Additional information on purpose of stay: /nformatlons camplémeniaies Sur Tabet du voyage ‘Member State of main destination (and other Member States of destination, i applicable): Ela membre de destination pinpal (et ates ais membres (de destination, le cas éean Member State offs entry: Eat 25, membre de premie ene: «Single entry / Une etree 9 Twoeentaes /Deuxentces 5 Multiple entries / Ents mutiles Nombre denées demandes: Intended dat of acval ofthe frst Intended dato of departure 27, Intended stay inthe Schengen trom the Schengen area area: Dae avd prévue pour le after the fist intended stay! premer séjour envsage dans Date de dépan prove de Tespace Senangen Tespace Senengen apes promer séjour envisage: Fingerprints collected previously No Non 5 Yes Oui {orthe purpose of applying fora Schengen visa?:/Empeeies Dato, known / Dato, si ‘ills releves précéderment aux 28, fas Cre demande de visa Schengen: \iea sticker number, if known / Numéro de Ia vonote-vsa,ses ann Entry permit for the final country of destination, where applicable: lssved by / Déiuée par [Auorsaton sero dans le pays de 28. gestnaion nate, cas échéant. Valid from / valable du Unis‘Surname and fist name ofthe inviting person(s) in the Member Stae(s). not applicable, name of hotels) or temporary acéommodation(s) in the Member Stat(s):/ Nom el prénom de lou des personnes qui intent dans Tat membye oulesElats membxes, A saul dom dn ou des Nes ou Heus) ‘dnebergement emporare(s) dans flat membre ou es Etats meréves “20 Address and e-mail address of inviting parson(syhotel(e temporary accommodation( invents ate ou des nately ou ds eux shabergement omporaie Tadresse o adresse Slecrondue dea ov des personnes qu Telaphone number: N°de phone "Name and address of inviing company/organisation:/Nom ol adresse de FenrepiselTonganisaon hate ‘Surname, frst name, address, telphone no. and e-mail address of contact person of companyforganisation: /Nom, prénom, adresse, n° do wibphone t 31 aesse electronique dela personne de contac dans Fentepisel organisation ‘Telephone number of companylorganisation:/7N' do tléphons de Fentoprice /organsation: Cos of traveling and lving during the applicant's stay i covered: /Les fai de voyage el de substance durant vote Stour son nancis: > By he applicant hinsetmersat par vous-néme 1 By a sponsor (host, company, organisation), please specify: /par un garant (hte, lentreprise, organisation, veullezprécer ‘Means of support // Moyens de susistance 4 Referred to infield 30 of 3 /vis dans la case 20 ou 24 a2, 2 Ca8h Argent iquse 4 Other (please speciy): are (precise): 1 Travellers eheques/ Cheques de voyage ‘5 Greiteard Carte de cst Means of support / Moyers de susistance: ‘5 Pre-paid accommodation / Hébergementprépayé ‘Prepaid transport Transpo prepay «2 Accommodation provided / Hébergement foun 1 Other (please speciy): Autes (a ibis 2 All expenses covered during the stay /Tous les fais sont fnancés pondante seu" 2 Pre-paid transport Transport prépaye 2 Other (please specity:/ Autes (a précis) am aware that the visa fee isnot refunded ifthe visas refused. de suis formé(e) que es drs de va ne sont pas rembourséssilevisa est reuse. ‘Applicable incase a multiple entry visa is applied for: ‘Apoleabe en cas de demande de aa entrées mutes 1am aware ofthe need to have an adequate travel medical insurance for my first stay and any subsequent visits to the toritory of Member Stats. Jesus nlmé(e de a ncessté de dsposer dune assurance malate en voyage adequate pour mon prenver sour et os de voyages uéieurs suri tee des Elats metres Tam aware of and consent tothe folowing: the collection ofthe data required by this application form and the taking of my photograph and, i applicable, ‘he taking of fingerprints, are mandatory fr the examination of the application; and any personal data concerning me which appear on the appiation form, ‘as well as my fingerprints and my photograph wil be supplied tothe relevant authorities of the Member States and processed by those authors, forthe purposes of a decision on my application Enconncisance de cause, j2cceplo ce qu cut: ux ns de fexamen de ma demande, ya You de rece ies données ruses dans co formulae, de me polograpnier ele cas échéant, de prenare mes empyentes digtales. Las données a caracére personne me concemant qui iguent das le présen formulae de ‘erande, ani que mes emprenes egal et ma photo, serontcommuniqudes aux autores competones des Etats mombres ot ates par els, aux ins de a ‘cision rate & ma demande. ‘Such data as well as data conceming the decision taken on my application or a decision whether to annul, revoke or extend a visa Issued will be entered Into, and stored inthe Visa Information System (VIS) for a maximum period of ve years, during which will be accessible tothe visa authorties and the lauthorties competent for carrying out checks on visa at extemal Borders and within the Member States, immigration and asylum authortes inthe Member ‘States for the purposes of vertying whether the conations for the legal erty into, stay and residence on the territory of the Member States are fulfiled, of identifying persons who do not of wh no longer full these conditions, of examining an asylum application and of detormining responsibilty or such ‘examination. Under certain conditions th data will be also avallablo to designated authortes ofthe Member States and to Europol forthe purpose of the prevention, detection and investigation of terorst offences and of other serious criminal offences. The authonty of the Member State responsible for processing the datas: jointly the Ministry of Foreign and European Affairs and Identity Malta Agency. ‘ces doonées ainsi que cols cancemant a décsion clave & ma demande, ou outa décsion 'nnulaton, abrogation ou de prolongation de visa, serotsasies et ‘conservées dans le systome clormaton sures visas (VIS) pendant une période maximale de Gna ans durant laquete elles serontaccassbles aux autores chargees es visas, aux autores compétentescharpées de contr es sas aux fonibes extreures et dans le Eats membres, aux autores compaétentes en mare ‘gimmgration et ase dans ios Eats mares aux ns do a voriiaton du respect des conditions dente ot do sejourregurs sure tortore des Eats mombres. do fidentfeaton des personnes qui ne remplesert pas ou pisces condos, de examen dune demande gasie et de la determination deFautort responsable de cet, ‘amen. Dans cecanes condtons, ces données Seon! aus accessibies aux autores dsinées des Etats memtres et Europl aux fins da prévertion et deta (biecton dos inactons terorstos ot des autres inaction pénalos graves, ani quaux ns des onqutos en la mabe. L'autrte do Etat meméxe compatonto pour traement des données est conontement avec le minster des Aares evangeres et europeennes et runt conval ds visas au sein de agence deny tataam awate that have the right o obtain, n any ofthe Member States, notification ofthe data relating to me recorded inthe VIS and ofthe Member Si which transmitted the data, and to request that data relating to me which are inaccurate be corrected and that data relating to me processed unlawfully be ‘eleted. Amy express request, the authory examining my application wal inform me of the manner in which I may exercise my right to check the personal ‘data conceming me and have them corrected or deleted, including the related remedies according tothe national aw of the Member State concemed. The ‘ftice of the Information and Data Protection Commissioner (dpe infogidpc.org.mt wil hea claims concerning the protection of personal data Idectare that tothe best of my knowledge al paniculars supplied by me are correct and complete. 1am aware that any false statements wil lead to my ‘application being rejected orto the annulment ofa visa already granted and may also render me lable to prosecution under the law ofthe Member State ‘which deals withthe application, Tundertake to leave the terior ofthe Member States before the expiry of the visa, if granted. | have been informed that possession ofa visa is only one of the prerequisites fr entry into the European teritory ofthe Member Stats. The mere fact that a visa has been granted tome does not mean that | wll be entitled to compensation Ifa to comply with the elevant provisions of Article 61) of Regulation (EU) No 2018/288 (Schengen Borders Code) and | am ‘therefore refused entry. The prerequisites for entry will be checked again on enty Into the European teritory of the Member States. Le sus formé(e) de mon dot obtenir ures de nimgorte quel tat membre Is noication des données ma concernant qul sont enregstras dans fe VIS ans que de ‘Etat membre qu tesa vansmses, el de demandes que les données me concemant Soin ecisies si etes sont eronées Oy elacées telson te ales de Tagen Floto. Ama demande express, autrte qul a oxainé ma demande minformora dela mane don je peux exerenr mon drt do verses donnbes a caractre personel me concemant et des fa ocifer eu Supptimer,y compris des vaes de cours prevses & cot gard parle dot natlonal de Etat mmbre concerns Cato de conte nationale dt Ela membre Le Comassarat &raformaton ea protection des données (dpe nfogdpe org enenda es relations ‘concernant la protection des données persomellespoura Bie sae des demandes concernant la protection des données 4 caractre personne. “de délare ult ma comaleeance, toes le hdostons que Js foumies sont corctes et completes, Je sul nformée) que tote fauseedécaration enraners ert ‘ema demande ou Fannin du vsa sia dj 8 de, e peut envainer des poursites pénales& mon gard en appication dy dot de FEtat membre qui tate ‘demande “le mfengage @ quitter terior des Ets membres avant fexpation du sa, i celui mest drs. 66 foo) que la possession un visa nest qu une des “onditons de Tend sure terior européen des Eats memes, Le snple fat quan visa at&t accord nimplque pas que faural do & une ndemnisaton sie ne ‘especte pas ls dispositions patnenes de Trice 6, paragraphe t, du réplment (UE) n° 2016/90 (coxe roves Schengen) et que Tencbe mest par conséquent felis. Le respect des condions entre sera via a nouveau au moment de entéesurletertor europe des Eats membres, Place and date: / Liou et date: ‘Signature / Signature (signature of parental authority / legal guard signature de Tautorté parentaleidu tuturlégal, le cas échéant)