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Gore Tex

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Анкета для отримання Шенгенської візи

Безкоштовний бланк

| | |
|Прізвище(-ща) (x) |wyłącznie do użytku |
|KLIMENTIEV |służbowego |
| | Data złożenia wniosku: |
|Прізвище (-а) при народженні/попереднє прізвище (-а)(х) | |
| | Numer wniosku: |
|Ім'я/Імена (x) | |
|ROMAN | |
| | | | Wniosek złożono: |
|Дата народження (рік-місяць-день) |Місце народження |7.Громадянство |□ w ambasadzie lub konsulacie |
| |M. KHARKIV |UKR |□ we wspólnym ośrodku |
|1985-08-04 |6.Країна народження |. Громадянство при народженні, |przyjmowania wniosków |
| |UKR |якщо відмінне від теперішнього: |□ u usługodawcy |
| | |USSR |□ u pośredniczącego podmiotu |
| | | |komercyjnego |
| | | |□ na granicy |
| | | | |
| | | | |
| | | |Nazwa: |
| | | | |
| | | |□ inne |
| | | |
|8. Стать |Громадянський стан | |
|X чоловік □жінка |□неодружений/незаміжня | |
| |X одружений/заміжня | |
| |□ роздільне проживання розведений/а | |
| |□ вдівець/вдова □ інше (зазначити) | |
| | |
|Для неповнолітніх: прізвище, ім'я, адреса (якщо відрізняється від адреси заявника) та громадянство особи, що має |Wniosek przyjęty przez: |
|батьківські права або є офіційним опікуном | |
|N/A | |
| | Dokumenty uzupełniające: |
|Ідентифікаційний код (якщо існує) |□ dokument podróży |
|3126219272 |□ środki utrzymania |
| |□ zaproszenie |
| |□ środek transportu |
| |□ podróżne ubezpieczenie |
| |medyczne |
| |□ inne: |
| | |
| |Decyzja o wizie: |
| |□ odmowa wydania wizy |
| |□ wiza przyznana: |
| |□ A |
| |□ C |
| |□ o ograniczonej ważności |
| |terytorialnej |
| | |
| |□ Termin ważności: |
| | |
|Вид проїзного документу: | |
|x закордонний паспорт □ дипломатичний паспорт □ службовий паспорт □ офіційний паспорт | |
|□ спеціальний паспорт □ інший проїзний документ (просимо вказати) | |
| | |п | | |
|Номер проїзного документу |Дата видачі |Дійсний до |Ким виданий | |
|FA779578 |04.09.2015 |04.09.2025 |6390 | |
| | | |
|Поштова адреса та адреса електронної пошти заявника |Номер(-и) телефонів | |
|M. KYIV, VUL. ZABOLOTNOHO 4, KV 53 |0995616169 | |
| | |
|18. Чи Ви постійно проживаєте в іншій державі ніж держава громадянства? | |
|x Ні | |
| | |
|□ Так. Дозвіл на проживання або рівноцінний документ ............Номер ............. Дійсний до | |
| | Od ……………………………. |
| | |
| |Do……………………………. |
| | |
| |Liczba wjazdów: |
| |□ 1 □ 2 □ wielokrotny |
| | |
| | |
|Посада (актуальна) | |
| | |
|Назва, адрес і номер телефону роботодавця. Для учнів і студентів - назва і адреса навчального закладу | |
| | |
| | Liczba dni: |
|Основна(-і) мета(-и) подорожі: | |
|x туризм □ службова поїздка □ відвідини родини або друзів □ культура □ спорт | |
|□ офіційний візит □ лікування □ навчання □ транзит □ транзитна зона аеропорту | |
|□ інше (просимо зазначити) | |
| | |

(x) . Пункти з 1по 3 повинні відповідати даним в проїзному документі
* На запитання відмічені зірочкою (*) не відповідають члени сім'ї громадянина ЄС, ЄЕП або Швейцарської Конфедерації (подружжя, діти або батьки на утриманні), які користуються правом вільного пересування. Родичі громадян ЄС, ЄЕП або Швейцарської Конфедерації мають подати документи, що підтверджують родинний зв'язок та заповнити пункти номер 34 і 35.

|Країна (-и) призначення |Країна(-и)-члени першого в'їзду | |
|POL |POL | |
| | | |
|24. Кількість в'їздів |25. Запланований час перебування або транзиту | |
|х один □ два □ багато |Просимо вказати кількість днів | |
| |4 | |
| | |
|Попередні Шенгенські візи (отримані впродовж останніх трьох років) | |
|□ні x так. Строк (-и) дії візи: 21.08.13-05.12.13; 20.05.14-19.11.14; 20.02.15-10.03.15; | |
|22.07.15-04.09.15 | |
| | |
|Чи при отриманні попередньої візи здавали Ви відбитки пальців | |
|x ні □ так | |
|Дата (якщо відома) ........................................................ | |
| | |
|Дозвіл на в'їзд до країни призначення (якщо стосується) | |
| | |
| | |
|Ким виданий .........................................................Дійсний від .................................до | |
|.................................... | |
| | |
| | | |
|Запланована дата в'їзду на територію Шенгенської зони |Запланована дата виїзду з території Шенгенської зони | |
|25-10-2015 |28-10-2015 | |
| | |
|Прізвище та ім’я особи чи осіб, яка(-і) запрошує (-ють) з держави-члена. Якщо не стосується, назва готелю(-ів) або | |
|адреса місця чи місць проживання заявника в державах- членах зони Шенген | |
|HOTEL HOLIDAY PARK 3* | |
| | | |
|Поштова адреса та адреса електронної пошти особи (осіб), що запрошують, |Номер телефону та факсу | |
|готелю(-ів),місця (місць) проживання | | |
| | | |
|ul. Heroldów 1B |+48 (22)865 27 70 | |
|01-991 Warszawa | | |
| | | |
|Назва та адреса фірми чи організації, що запрошує |Номер телефону фірми чи організації | |
| | | |
| | |
|Прізвище, ім’я, адреса, номер телефону та факсу, адреса електронної пошти контактної особи у фірмі чи | |
|організації: | |
| | |
|Витрати на подорож і проживання заявника під час його перебування покриває | |
| | | |
|x сам заявник |□ приймаюча сторона (особа, що запрошує, фірма, організація) , | |
|Кошти утримання: |просимо зазначити | |
|x готівка |□ вказане в пунктах 31 або 32 | |
|□ подорожні чеки |□ інше (посимо зазначити) | |
|x кредитна картка | | |
|x оплачене житло |Кошти утримання: | |
|x оплачений транспорт |□ готівка | |
|□ інше (просимо зазначити) |□ заявнику надається житло | |
| |□ бере на себе всі витрати під час перебування | |
| |□ оплачений транспорт | |
| |□ інше (просимо зазначити) | |
| | | |
| | | |
| | | |
| | |
|Особисті дані члена сім'ї, який є громадянином ЄС, ЄЕП або Швейцарської Конфедерації N/A | |
| |Ім'я | |
|Прізвище | | |
| |Громадянство | Номер проїзного документу чи | |
|Дата народження | |посвідчення особи | |
| | | | |
| | |
|Спорідненість із громадянином ЄС, ЄЕП або Швейцарської Конфедерації | |
|□ чоловік/дружина □ син/донька □ онук/онука □ мати/батько/бабуся/дідусь на утриманні | |
| | | |
|Місце і дата |Підпис (замість неповнолітньої дитини підписує один з | |
| |батьків або опікунів) | |
|KYIV 13.10.2015 | | |

| |
|Мені відомо, що відмова у видачі візи не є приводом для повернення організаційних витрат |

| |
|Для заявників на багаторазову візу (див. пункт № 24): |
| |
|Мені відомо, щодо необхідності мати медичну страховку як для першої подорожі, так і для наступних поїздок на територію держав-членів ЄС |

| |
|Мені відома наступна інформація і я з нею погоджуюсь: дані, які потрібно вказати в цій заяві, надання фотографії і, у разі необхідності відбитки |
|моїх пальців є обов'язковими для розгляду заяви на отримання візи; мої персональні дані та дані вказані в анкеті на отримання візи, а також мої |
|відбитки пальців та фотографія будуть передані до компетентних органів держав-членів ЄС та розглядатимуться цими органами при прийнятті рішення |
|щодо видачі візи. |
| |
|Ця інформація, в також рішення щодо заяви на отримання візи, анулювання, відміни або подовження виданої візи зберігатиметься у системі VIS |
|протягом п'яти років та буде доступною для компетентних органів, що здійснюють візовий контроль на зовнішніх кордонах на території держав-членів |
|ЄС; для міграційних служб, установ, що розглядають надання політичного притулку держав-членів ЄС з метою перевірки виконання вимог в'їзду, |
|законного перебування та проживання на території держав-членів ЄС; з метою встановлення особистості осіб, які не дотримуються або перестали |
|виконувати ці вимоги; з метою вивчення заяви на отримання політичного притулку та встановлення ступені відповідальності за це. У певних випадках, |
|також зможуть перевіряти ці дані компетентні органи держав ЄС та Європол з метою уникнення, розкриття або розслідування терористичних або інших |
|тяжких злочинів. Відповідальним органом держави-члена за обробку цих даних є: Управління у справах Іноземців, вул.. Кошикова, 16, 00-564 Варшава. |
| |
| |
|Мені відомо, що я маю право отримати від будь-якої держави-члена ЄС інформацію щодо моїх персональних даних, які фігурують в системі VIS та яка |
|держава їх внесла, а також вимагати виправити ту інформацію, яка є неточною та видалити ті дані, які були отримані нелегально. На моє клопотання, |
|установа, яка обробляє мою заяву, має мене поінформувати яким чином я можу перевірити мої персональні дані та яким чином можна їх виправити або |
|знищити та як це зробити відповідно до внутрішнього законодавства країни-члена ЄС до якої я звернувся. Скарги щодо охорони даних персональних |
|будуть розглядатися національною установою держави-члена, що здійснює контроль: Генеральний Інспектор Захисту Особистих Даних, вул.. Ставки, 2, |
|00-193 Варшава. |
| |
|Я заявляю, надав правдиві дані у повному обсязі. Мені відомо, що будь-яка неправдива інформація може стати приводом для відмови у видачі візи, в |
|анулюванні виданої візи і може підлягати кримінальній відповідальності, відповідно до законодавства держави-члена ЄС, яка розглядає мою заяву на |
|отримання візи. |
| |
|Я зобов'язуюся покинути територію держави-члена до закінчення строку дії виданої візи. Мене поінформували, що віза – це одна з вимог для в'їзду на |
|територію держав-членів ЄС. Факт отримання візи не означає, що я маю право на відшкодування , якщо я порушив положення статті 5, пункту 1 |
|Регламенту ЄС № 562/2006 (Шенгенський прикордонний кодекс), внаслідок чого мені заборонили в'їзд до країни призначення. Виконання вимог в'їзду |
|перевірятиметься при в'їзді на територію держав-членів ЄС. |
| |
| | |
|Місце і підпис |Підпис (замість неповнолітньої дитини підписує один з батьків або опікунів) |
| | |
|KYIV 13.10.2015 | |
| | |
| | |
| | |

___________ З моменту функціонування системи VIS
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