15.9.2009 Ca Official Journal of the European Union ANNEX 1 Harmonised application form *) Application for Schengen Visa ‘This application form i free L 24327 PHOTO 1, Sumame (Family name) €) or offical we only 2, Surname at Bint (Former family amet) (8 Date of appliation 3. ist name(s) (Given narefl 8) “4 Date of bith day-mont-yea | 5. Pace of bit 6 County of bith 7. Curent nationality Nationalgy at bith, if diferent ‘Visa appicsion mb: Applicaton lodged at 1 Embassyconsuate Geac DD Sevce provider 8. Sex 9, Merial status Cy Other lease speci 1 Male (0 Female {D Single) Narved Cy Separated (] Divored [] Widowte) 1G Commer intermediary 1D Bower Name sathorsylegal gardan Tou be a fing Sua are as (et rom appa) and any of paca |} le tuned by TT Nason Westy be, here appiale supporting dosent: TE ype of wae doament Tove doceit Meas of eb 1 onion pp 1 Dp payor Servic poset} fal pepe I Sel ppt 1D Means of subsisence Fy omer coe document lee seh 1 tnvtason 1 Means of rangor 1 Numer of ee Ta Daw ofan |S Yad na 16 ad by an soameat Ce: 77. plans ome ais and ma ade Teephone mabe Misa dion | [eer ta etn Ta Rene a» coy oer thant county of eet matonalty D tem or 7 1D Yes Reece permit repre nme NO _ vad wt Ow +19, Curent occupation establishment 22 Main purpose) of the journey 1D Tourism () Busines Vising fay or feds) Cabral C) Spons 1G Offical vit 1 Mati rexsons | __Csnay Tan or ws os en spsif) To. Employer and employ’ adres and eephone number, For sun name ad sre of evans amber of nae: 110 2D Matple Number of days No logo by vequred for Norway, lend and SwitzetandL 243/28 ta Official Journal of the European Union 159.2009 22, Member State) of destination 723, Member State of fist entry 24, Number of ents requested 25, Duration ofthe incended stay oF transit 1D Single entry () Two enuies > Indicate number of days Gy Multpe ens . “Guana wih al exe led by faly meres of BU, EA or CH ines ous cdo dependent enn whe thet ight to free movement. Fay members iy eT een dll present document o proves rationship and lin Belds No 34 35. (9) Fede 13 call be filed in in accordance wh the data in the travel document 126, Schengen vist sued during the past thee years ON. ’ 1D Yes, Datei of vali from amano 727, Fngarpring coleced previously for the purpose of eplyng fora Schengen visa Ovo re “8 Ennry permit forthe final country of destination, where applicable IexuedbY eoenm Valid fF0m a mck ofa me Scngen we 30 edad he of dpe me Shen we Ty, Sumame and fit name ofthe ivng parton) im the Member Ste) If not applicable, name of ote) ‘Srmporary accommodaton() in the Member ttt) “padres and eral address of inviting persoioteleemporay | Telephone and telex ‘ccommodaon() scommorn__ +32. Name and address of inviting companyorganisaton "Tdephone and telex of companyloranist- ton ‘Srmame, fst mame, adres, Wlephone tee, and e-mail address of contact person in companyforansaton 733, Cost of eavelling and living during the applicants stay i cover 1 by the applicant hse C1 bys pomer fo come omni Means of support 1D refered to fd 31 0 32 ooh “Dh athe (ee se 1D Tavs cheques 1 cele cd 1D repaid accommodation 1B Accommadton provided 1D Prepaid transport 0) Al expenses covered ding the sar CD Other (please specify) Dl Prepaid transport9 15.9.2009 fo Official Journal of the European Union L 243/28 ya Penna dita of the family member who is an EU, EEA or CH ctizen ‘Sumamne Fist names) Date of bir Nationality ‘Number of tavel document or 1D card 135, Family relationship with an EU, EEA or CH ckizen 1D epee [eid enn sr dependent scence 36, Pace and date 7 Sigowture for minors, signature of parental aucboriyegal urd) Tram avare thatthe visa fee A not refunded the vin i refed “Appeal in case a mlipp-eny vin i appl for (cid No 24 aera of the net to have am adequate travel ca surance for my Bi ay ad ny abet ws othe eon of Meet SS Tr of and conse ote flowing te clean ofthe da oud by hs pao form and he ig of my Hg) aa Sag of ngs, mandatory forthe ana of te vi eben: A ena or "wich appear anole he hg oe my Hngrping tod my phosogph wl be spied th ran hrs ofthe Mees So nd ors SF hy tbo utr, for the purpose f+ decison on my wk aplication. aon cw ss dan conteng he deconakn on my appvcaon ra decom wn to sana ris or und Ws GS! DS Such ana wel a cn ae Sy (9) () fra minum ped of re yea Ging wich wile se Le a cay out cin ons a exer bodes nd itn he Merb Sas ean $05 7 Suthortes inthe Member States forthe ecg eng whe the cnn fr te lege ne say and reece on te ton the Member Sates ae full, of ei eras nox ox eho ong al tee condon, of amining 2x syn applcaen ond the Memb Seta ot mon, Une cea condos th ta wl be ds real 1 senda fs Da of tem esposbilyfo h percton écecon and etgton of erst es and of rss criminal fees The ‘TShomy of the Member Sute responsible for processing the data (}- aanrre tha thee gh to bin any ofthe Mei Sas oan fhe at ring te rede eS nf Os et {am ar mined the ata, and 10 seq hat ta rating te which are inact be como State whch wand th a fg he eshotyexamcing my apn wl norm me of te manner wih |e right to check the nT ee hem cone or Cc, niodig the aed veer sczrting to the ots et the State con Sr a ony ta Meer Ste [enact Gea wl ear cms concerning the promton of peso a vine hat the bs of my nove al pus sopplid by me ae cc sd complet, am me ht ny fle ames ISH ay it ee fy ow ent of? ws dy uted ad may Aso Fen me lable to rseton wd i eof he ‘Member state which das with the application. porate tae etry othe Mer Stes oe he xy of vin nt har ben fol hat ont of TS dere to as he ort oe Europea err of te Mere Sue. The mer have Bm BS oF 0 gen ‘hat Lwil be ended to compensation if [fall comply with the revert eof Arde 51) of Regulation (EC) No $62/2008 Schengen Bksere Cove) and Tam thertore ese enty. Te prerequisites fr entry rch again on entry ita the Earopean terry ofthe Member States. Place and date ‘Signature for minocs, signature of parental authoriylegal guaran: @) nwo Bara the VIS is operons