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 /
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) 6. Locul i ara naterii/ Place and country of birth Documente doveditoare: 7. Cetenia prezent/Current nationality/ies 9. Sexul/Sex 8. Cetenia la natere/Original nationality (nationality at birth) 10. Statut civil/Marital status : Celibatar/Single Cstorit/Married Separat/Separated Vduv()/Widow(er) 11. Prenumele tatlui/Fathers name Divorat/Divorced Altele/Other 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))

5. CNP/ ID-number

Document procesat de :

Brbtesc/Male

Femeiesc/Female

12. Prenumele mamei/Mothers name

13. Document de cltorie/Type of passport:

Paaport 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.)

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)

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 :

Tranzit aeroportuar/Airport transit

Tranzit/Transit Scurta sedere/ short stay 24. Nr. de intrri solicitate/No. of entries requested

23. Viz/Visa : Individual/Individual Colectiv/Collective

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

25.Durata ederii/ Duration of stay

Unic intrare/Single entry Dou intrri/Two entries Multiple intrri/Multiple entries

Viza solicitat pt./Visa is requested for: .. zile/days

Multiple

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

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 sau n alte State Schengen/Previous stays in Romania or other Scengen States

29. Scopul ederii n Romnia/Purpose of travel FOR EMBASSY /

Misiune (C/M)/Official Transport (C/TR)/ Transportation) Vizit (C/VV)/Visit to Family or Friends Activiti sportive (C/SP) /Sport

Afaceri (C/A)/Business Turism (C/TU)/Tourism Activiti culturale, tiinifice, umanitare, tratament medical de scurta durata care nu contravin legilor romne (C/ZA)/ Other activities

CONSULATE USE ONLY

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

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

*32. Punctul de intrare, sau traseul de tranzit/Border of first entry or transit route

*33. Mijloc de transport/Means of transport

*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 Adresa complet/Full address

Tel. i fax/phone and fax no. 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 Cazare pltit/Accommodation Altele/Other: Asigurare medical valabil pn la/Travel and/or health insurance. Valid until: .............................................................................................................................
37. Numele soului(soiei)/Spouses family name 39. Prenumele soului(soiei)/ Spouses first name

Cri de credit/Credit cards

38. Numele la natere al soului(soiei)/ Spouses family name at birth

40.Data de natere a soului (soiei)/ 41. Locul de natere al soului(soiei)/ 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 Nr. de paaport/Number of passport Legtura familial/Family relationship : Prenume/First Name Data naterii/Date of Birth

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.

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)

(*) 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.