Schengen Visa Application Form - Poland

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Photo
VISA APPLICATION FORM
Stamp of office
Issuing visa
1. Surname
FOR CONSULATE USE
ONLY
Data złożenia wniosku:
2. Maiden name / Previous surnames
Przyjmujący wniosek:
3. Given names
4. Date of birth (YY – MM - DD)
5. Identification number (if applicable)
Dodatkowe dokumenty:
6. Place and country of birth
Ważny dokument
podróży
7. Present citizenship(s)
8. Citizenship at birth
Zaproszenie
Środek transportu
9. Sex
10. Marital status
Ubezpieczenie
male
female
single
married
separated
Inne:
divorced
widowed
other
11. Father’s given name
12. Mother’s given name
Wiza:
13. Type of travel document
Odmowa
Passport
Diplomatic passport
Service passport
Travel document for aliens
Udzielona
Travel document (as in Geneva Convention of 1951)
Seaman’s book
Other travel document (what type):
..........................................................................................................................................
Typ wizy / cel pobytu:
14. Travel document number
15. Issued by
A
B
16. Date of issue
17. Valid until
C /..........
D /..........
W /..……
18. If you reside in another country than country of your origin – do you have permission to return to this
country?
No
Yes (document number and date of validity)
.....................................................................................
19. Present job
20. Employer’s address and telephone number. For students – name and address of school / university
21. Country of destination (in case of
22. Visa class
23. Visa applies to:
Ilość wjazdów:
transit)
Airport
One person
1
2
wiele
Transit
More * ........(how many)
Ważna od ........................
do ....................................
Short stay
Long stay
Entry
24. Number of entries requested
25. Period of stay:
Ważna na .................. dni
single entry
double entries
multiple entries
visa is requested for _________ days
26. Polish visa(s) (issued in last 3 years) and their period(s) of validity:
27. If you are applying for a transit visa, do you have permission to enter a country of destination?
Pieczęć i podpis organu
wydającego wizę
No
Yes, valid until do:
issued by:
* 28. Countries visited in the last 5 years
* Only applicable when multiple family members are included in one travel document.
Photo
VISA APPLICATION FORM
Stamp of office
Issuing visa
1. Surname
FOR CONSULATE USE
ONLY
Data złożenia wniosku:
2. Maiden name / Previous surnames
Przyjmujący wniosek:
3. Given names
4. Date of birth (YY – MM - DD)
5. Identification number (if applicable)
Dodatkowe dokumenty:
6. Place and country of birth
Ważny dokument
podróży
7. Present citizenship(s)
8. Citizenship at birth
Zaproszenie
Środek transportu
9. Sex
10. Marital status
Ubezpieczenie
male
female
single
married
separated
Inne:
divorced
widowed
other
11. Father’s given name
12. Mother’s given name
Wiza:
13. Type of travel document
Odmowa
Passport
Diplomatic passport
Service passport
Travel document for aliens
Udzielona
Travel document (as in Geneva Convention of 1951)
Seaman’s book
Other travel document (what type):
..........................................................................................................................................
Typ wizy / cel pobytu:
14. Travel document number
15. Issued by
A
B
16. Date of issue
17. Valid until
C /..........
D /..........
W /..……
18. If you reside in another country than country of your origin – do you have permission to return to this
country?
No
Yes (document number and date of validity)
.....................................................................................
19. Present job
20. Employer’s address and telephone number. For students – name and address of school / university
21. Country of destination (in case of
22. Visa class
23. Visa applies to:
Ilość wjazdów:
transit)
Airport
One person
1
2
wiele
Transit
More * ........(how many)
Ważna od ........................
do ....................................
Short stay
Long stay
Entry
24. Number of entries requested
25. Period of stay:
Ważna na .................. dni
single entry
double entries
multiple entries
visa is requested for _________ days
26. Polish visa(s) (issued in last 3 years) and their period(s) of validity:
27. If you are applying for a transit visa, do you have permission to enter a country of destination?
Pieczęć i podpis organu
wydającego wizę
No
Yes, valid until do:
issued by:
* 28. Countries visited in the last 5 years
* Only applicable when multiple family members are included in one travel document.
29. Purpose of travel
FOR CONSILATE USE
Tourism
Visit
Sport
Business
Culture
Official
ONLY
Work
Education
Other (specify):
..........................................................................................................................................
30. Date of entry
31. Date of departure
32. Border crossing point or transit route
33. Means of transport
34. Information about a person or a company hosting you while in Poland. If this does not apply, give the name
of your hotel or other temporary address in Poland:
Given name and surname/Name of company
Tel. and fax numbers
Full address
E-mail
35. Who is covering the costs of your travel and stay?
applicant
person making invitation / sponsor
other
(please specify who and how, and enclose appropriate documents)
..............................................................................................................................................
..............................................................................................................................................
36. Means to cover costs of your stay:
Cash
Traveller’s cheques
Credit cards
Pre-paid services
Others:
Travel insurance / health insurance. Valid until:
...............................................................................................
**37. Applicant’s spouse
**38. Maiden name
**39. Given name
**40. Date of birth
**41. Place of birth
**42. C
HILDREN
Surname
Given name
Date of birth
1 .............................................................................
....................................................... .................................
2 .............................................................................
....................................................... .................................
3 .............................................................................
....................................................... .................................
***43. Exceptional and urgent reasons requiring entry to and stay in Poland
............................................................................................................................................................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
............................................................................................................................................................................................
44. I agree that personal data on this application form may be recorded by the appropriate authorities of the Republic of
Poland and processed if necessary, for the issuing of a visa.
I declare that to the best of my knowledge the above particulars are correct and complete. I am aware that any false
statements will lead to my application being rejected or to the invalidation of the visa already granted and may also
render me liable to prosecution under the law of the Republic of Poland.
I undertake to leave the territory of the Republic of Poland upon the expiry of the visa, if granted.
I realise that the possession of a visa is only one of the conditions of entry to the territory of the Republic of Poland.
Acquiring a visa does not entitle me to compensation should entry to the Republic of Poland be refused by officers of
the Border Guard.
45. Applicant’s address in the country of residence
46. Telephone number
48. Signature (in case of minor,
47. Place and date
signature of legal representative)
** Applies to family members included in a travel document of an alien, who accompany him/her during a trip to Poland.
*** To be filled in by an alien applying for a visa to the relevant commanding officer of the Border Guard checkpoint – according to the article 47
section 1 of the Aliens Act of 13 June 2003

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