Schengen Visa Application Form - English/Arabic

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Application for Schengen Visa
PHOTO
This application form is free
‫يكبٌ انصٕسة انشخصٛت‬
ٍ
‫ــــــ‬
‫غ ـ‬
‫ـــــ‬
ُ‫ؽهت رؤشٛشح ش‬
‫ْزِ االسزًبسح يجبَٛخ‬
‫اسى انؼبئهخ‬
1 -
F
1. Surname (Family name) (x)
OR OFFICIAL USE ONLY
‫اسى انؼبئهخ ػُذ انٕالدح‬
2 -
Date of application:
2. Surname at birth (Former family name(s)) (x)
Visa application number:
‫االسى األٔل‬
3 -
3. First name(s) (Given name(s)) (x)
Application lodged at
□ Embassy/consulate
‫ربسٚخ انًٛالد‬
4 -
‫يكبٌ انًٛالد‬
‫انجُسٛخ انذبنٛخ‬
7 -
5 -
4. Date of birth
5. Place of birth
7.Current nationality
□ CAC
)
‫انسُخ‬
-
‫انشٓش‬
-
‫انٕٛو‬
(
(day-month-year)
□ Service provider
□ Commercial intermediary
‫ثهذ انًٛالد‬
6 -
‫انجُسٛخ ػُذ انٕالدح‬
6. Country of birth
Nationality at birth,
□ Border
‫الف‬
‫فٙ دبل االخز‬
if different:
Name:
‫انجُس‬
‫انذبنخ االجزًبػٛخ‬
9 -
8 -
9. Marital status
8. Sex
□ Other
‫ركش‬
□ Male
/ ‫ح‬
‫أػضة‬
□ Single
□ Married
/ ‫ح‬
‫يزضٔط‬
ٗ‫أَث‬
□ Female
File handled by:
/ ‫ح‬
‫يُفظم‬
/ ‫ح‬
‫يطهك‬
□ Separated □ Divorced
)
‫دذد‬
(
ٖ‫أخش‬
□ Widow(er) □ Other (please specify)
/ ‫ح‬
‫أسيم‬
Supporting documents:
ٍ‫ػ‬
‫ٚخزهف‬
‫فٙ دبل‬
(
ٌ‫ٚزكش اسى انؼبئهخ ٔ االسى األٔل ٔ انؼُٕا‬
:
‫فٙ دبل انمظش‬
-
10
10. In the case of minors: Surname, first name, address
□ Travel document
ٙ‫ٔنٙ األيش أٔ انٕط‬
/
‫انجٓخ‬
/
ٍٚ‫ٔ جُسٛخ انٕانذ‬
)
‫يزمذو انطهت‬
(if different from applicant's) and nationality of parental
□ Means of subsistence
authority/legal guardian
□ Invitation
□ Means of transport
□ TMI
□ Other:
‫سلى ثطبلخ انٕٓٚخ انشخظٛخ انًسزخذيخ‬
-
11
11. National identity number, where applicable
Visa decision:
□ Refused
‫َٕع ٔصٛمخ انسفش‬
-
12
12. Type of travel document
□ Issued:
□ Ordinary passport
□ Diplomatic passport
ٙ‫□ جٕاص سفش دثهٕيبس‬
٘‫□ جٕاص سفش ػبد‬
□ A
□ C
□ Service passport
□ Official passport □ Special passport
‫□ جٕاص سسًٙ □ جٕاص خبص‬
‫□ جٕاص خبص نًًٓخ‬
□ VTL
)
‫ٚشجٗ انزذذٚذ‬
(
ٖ‫يسزُذاد سفش أخش‬
□ Other travel document (please specify)
□ Valid:
‫سلى ٔصٛمخ انسفش‬
-
13
‫ربسٚخ اإلطذاس‬
-
14
‫طبنذخ نغبٚخ‬
-
15
ٍ‫طبدسح ػ‬
-
16
13. Number of
14. Date of issue
15. Valid until
16. Issued by
From
travel document
Until
Number of entries:
:
َٙٔ‫نكزش‬
‫انؼُٕاٌ انذائى نطبنت انزؤشٛشح ٔ ػُٕاَّ اال‬
-
17
‫ْبرف‬
17. Applicant's home address and e-mail address
Telephone number(s)
□ 1 □ 2 □ Multiple
Number of days:
:
‫فٙ غٛش ثهذ انجُسٛخ‬
‫اإللبيخ‬
ٌ‫ػُٕا‬
-
18
18. Residence in a country other than the country of current nationality
□ No
‫□ ال‬
□ Yes. Residence permit or equivalent …………………………. No. …………………………… Valid until………………………..
.....
.....................................
‫طبنذخ نغبٚخ‬
..
.................................
:
‫سلًٓب‬
.
....................
‫اإللبيخ‬
‫سخظخ‬
:
‫َؼى‬
......
................
..................
‫بنٛخ‬
‫انٕظٛفخ انذ‬
-
19
*
* 19. Current occupation
* The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to
free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields no 34 and 35.
(x) Fields 1-3 shall be filled in accordance with the data in the travel document.
.
‫ٚجب أٌ حعبأ طبمب نهًعهٕيبث انًذَٔت بٕثٛمت انسفش‬
3
‫إنٗ انحمم‬
1
‫يٍ انحمم‬
‫ش نٛس عهٛٓى‬
‫انهزٍٚ لذ ٚسبفشٔا يسخعًهٍٛ حمٓى ببنخجٕال انح‬
)
‫األصٔاج، األٔالد أٔ األلشببء األكبش سُب يُّ ٔ يخكفم بٓى‬
(
٘‫ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش‬
*
.
33
ٔ
33
‫بئت انحمهٍٛ سلى‬
‫عهٗ ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش٘ حمذٚى انًسخُذاث انز٘ حثبج ْزِ انمشابت ٔ حع‬
.
‫حعبئت انفشاغبث انًؤششة بُجًت‬
Application for Schengen Visa
PHOTO
This application form is free
‫يكبٌ انصٕسة انشخصٛت‬
ٍ
‫ــــــ‬
‫غ ـ‬
‫ـــــ‬
ُ‫ؽهت رؤشٛشح ش‬
‫ْزِ االسزًبسح يجبَٛخ‬
‫اسى انؼبئهخ‬
1 -
F
1. Surname (Family name) (x)
OR OFFICIAL USE ONLY
‫اسى انؼبئهخ ػُذ انٕالدح‬
2 -
Date of application:
2. Surname at birth (Former family name(s)) (x)
Visa application number:
‫االسى األٔل‬
3 -
3. First name(s) (Given name(s)) (x)
Application lodged at
□ Embassy/consulate
‫ربسٚخ انًٛالد‬
4 -
‫يكبٌ انًٛالد‬
‫انجُسٛخ انذبنٛخ‬
7 -
5 -
4. Date of birth
5. Place of birth
7.Current nationality
□ CAC
)
‫انسُخ‬
-
‫انشٓش‬
-
‫انٕٛو‬
(
(day-month-year)
□ Service provider
□ Commercial intermediary
‫ثهذ انًٛالد‬
6 -
‫انجُسٛخ ػُذ انٕالدح‬
6. Country of birth
Nationality at birth,
□ Border
‫الف‬
‫فٙ دبل االخز‬
if different:
Name:
‫انجُس‬
‫انذبنخ االجزًبػٛخ‬
9 -
8 -
9. Marital status
8. Sex
□ Other
‫ركش‬
□ Male
/ ‫ح‬
‫أػضة‬
□ Single
□ Married
/ ‫ح‬
‫يزضٔط‬
ٗ‫أَث‬
□ Female
File handled by:
/ ‫ح‬
‫يُفظم‬
/ ‫ح‬
‫يطهك‬
□ Separated □ Divorced
)
‫دذد‬
(
ٖ‫أخش‬
□ Widow(er) □ Other (please specify)
/ ‫ح‬
‫أسيم‬
Supporting documents:
ٍ‫ػ‬
‫ٚخزهف‬
‫فٙ دبل‬
(
ٌ‫ٚزكش اسى انؼبئهخ ٔ االسى األٔل ٔ انؼُٕا‬
:
‫فٙ دبل انمظش‬
-
10
10. In the case of minors: Surname, first name, address
□ Travel document
ٙ‫ٔنٙ األيش أٔ انٕط‬
/
‫انجٓخ‬
/
ٍٚ‫ٔ جُسٛخ انٕانذ‬
)
‫يزمذو انطهت‬
(if different from applicant's) and nationality of parental
□ Means of subsistence
authority/legal guardian
□ Invitation
□ Means of transport
□ TMI
□ Other:
‫سلى ثطبلخ انٕٓٚخ انشخظٛخ انًسزخذيخ‬
-
11
11. National identity number, where applicable
Visa decision:
□ Refused
‫َٕع ٔصٛمخ انسفش‬
-
12
12. Type of travel document
□ Issued:
□ Ordinary passport
□ Diplomatic passport
ٙ‫□ جٕاص سفش دثهٕيبس‬
٘‫□ جٕاص سفش ػبد‬
□ A
□ C
□ Service passport
□ Official passport □ Special passport
‫□ جٕاص سسًٙ □ جٕاص خبص‬
‫□ جٕاص خبص نًًٓخ‬
□ VTL
)
‫ٚشجٗ انزذذٚذ‬
(
ٖ‫يسزُذاد سفش أخش‬
□ Other travel document (please specify)
□ Valid:
‫سلى ٔصٛمخ انسفش‬
-
13
‫ربسٚخ اإلطذاس‬
-
14
‫طبنذخ نغبٚخ‬
-
15
ٍ‫طبدسح ػ‬
-
16
13. Number of
14. Date of issue
15. Valid until
16. Issued by
From
travel document
Until
Number of entries:
:
َٙٔ‫نكزش‬
‫انؼُٕاٌ انذائى نطبنت انزؤشٛشح ٔ ػُٕاَّ اال‬
-
17
‫ْبرف‬
17. Applicant's home address and e-mail address
Telephone number(s)
□ 1 □ 2 □ Multiple
Number of days:
:
‫فٙ غٛش ثهذ انجُسٛخ‬
‫اإللبيخ‬
ٌ‫ػُٕا‬
-
18
18. Residence in a country other than the country of current nationality
□ No
‫□ ال‬
□ Yes. Residence permit or equivalent …………………………. No. …………………………… Valid until………………………..
.....
.....................................
‫طبنذخ نغبٚخ‬
..
.................................
:
‫سلًٓب‬
.
....................
‫اإللبيخ‬
‫سخظخ‬
:
‫َؼى‬
......
................
..................
‫بنٛخ‬
‫انٕظٛفخ انذ‬
-
19
*
* 19. Current occupation
* The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to
free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields no 34 and 35.
(x) Fields 1-3 shall be filled in accordance with the data in the travel document.
.
‫ٚجب أٌ حعبأ طبمب نهًعهٕيبث انًذَٔت بٕثٛمت انسفش‬
3
‫إنٗ انحمم‬
1
‫يٍ انحمم‬
‫ش نٛس عهٛٓى‬
‫انهزٍٚ لذ ٚسبفشٔا يسخعًهٍٛ حمٓى ببنخجٕال انح‬
)
‫األصٔاج، األٔالد أٔ األلشببء األكبش سُب يُّ ٔ يخكفم بٓى‬
(
٘‫ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش‬
*
.
33
ٔ
33
‫بئت انحمهٍٛ سلى‬
‫عهٗ ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش٘ حمذٚى انًسخُذاث انز٘ حثبج ْزِ انمشابت ٔ حع‬
.
‫حعبئت انفشاغبث انًؤششة بُجًت‬
‫انؼًم ٔ سلى انٓبرف‬
‫سة‬
ٌ‫ػُٕا‬
-
20
*
* 20. Employer and employer's address and telephone number.
‫اسى ٔ ػُٕاٌ انجٓخ انزؼهًٛٛخ‬
:
‫فٙ دبل انطهجخ‬
For students, name and address of educational establishment.
am aware that once the visa
I
request has been submitted,
a copy of the form, sealed
with the indication of the
date and place of reception,
shall be returned to the
applicant
and
that
arrangements can be made
with the applicant as to the
channel
to
request
corrections or the supply of
documents or certificates, as
‫انٓذف انشئٛسٙ نهسفش‬
-
11
21. Main purpose(s) of the journey:
well as to serve notice of
summons and to notify the
□ Tourism □ Business □ Visiting family or friends
‫خ أٔ أطذلبء‬
ٛ‫صٚبسح ػبئه‬
‫أػًبل رجبسٚخ‬
‫سٛبدخ‬
decision adopted
in
due
course.
‫أسجبة‬
□ Cultural □ Sports
□ Official visit
‫بسح سسًٛخ‬
ٚ‫ص‬
‫سٚبػٛخ‬
‫خ‬
ٛ‫صمبف‬
‫أسجبة ؽجٛخ‬
□ Medical reasons
□ Study □ Transit
‫يشٔس‬
‫دساسخ‬
Notices and requests shall be
served by telephone or fax to
□ Airport transit
□ Other (please specify)
)
‫ٚشجٗ انزذذٚذ‬
(
‫غٛشْب‬
‫فٙ انًطبس‬
‫يشٔس‬
the contact number provided
by the interested party or
‫انذٔنخ انؼؼٕ انًمظٕدح ثبنسفش‬
-
22
ٍ‫شُف‬
‫دٔنخ انذخٕل األٔل نًُطمخ‬
-
23
22. Member State(s) of destination
23. Member State of first entry
his/her legal representative.
If
they
were
to
prove
ineffective, they shall be
served in writing to the
domicile
set out in the
application, which must be
‫انًطهٕة‬
‫ػذد يشاد انذخٕل‬
-
24
‫أٔ فزشح انؼجٕس‬
‫خ‬
‫نًكٕس انًزٕلؼ‬
‫يذح ا‬
-
25
24. Number of entries requested
25. Duration of the
located within the consular
‫ٚشجٗ رذذٚذ ػذد األٚبو‬
intended stay or transit
□ Single entry
‫ذح‬
‫سفشح ٔاد‬
district.
Indicate number of days
□ Two entries
ٍٛ‫ر‬
‫سفش‬
Summons
and
requests
□ Multiple entries
‫يزؼذدح انسفشاد‬
served must be complied
with within a period not
‫سُٕاد األخٛشح‬
‫س‬
‫انظبدسح خالل انضال‬
ٍ
‫ُغ‬
‫ش‬
‫ػذد رؤشٛشاد‬
-
26
26. Schengen visas issued during the past three years
exceeding ten days, unless
personal
attendance
is
□ No
‫□ ال‬
required in which case the
□ Yes. Date(s) of validity from …………………. to ………………..
deadline is fifteen days.
................................
:
ٗ‫إن‬
...........................
:
ٍ‫ي‬
)
‫أركش انزبسٚخ نٕ كبٌ يؼهٕيب‬
(
‫رؼى‬
Once all the possibilities of
serving a notice have been
exhausted, the notice shall be
served by means of an
‫ٍ غ‬
ُ‫ؤشٛشاد ش‬
‫انجظًبد انًؤخٕرح سبثمب نطهجبد ر‬
-
27
27.Fingerprints collected previously for the purpose of applying for a Schengen visa
announcement posted at the
relevant notice board of the
□ No
‫□ ال‬
Embassy
or
Consulate
□ Yes. Date, if known:
‫َؼى ، انزبسٚخ إٌ كبٌ يؼهٕيب‬
during ten days.
‫رظشٚخ يٕافمخ انذخٕل نهجهذ انًمظٕد ثبنسفش إٌ ٔجذ‬
-
28
If no reply is received to a
28. Entry permit for the final country of destination, where applicable
request or summons, the
applicant shall be deemed to
Issued by ………………………………..Valid from …………………………until…………………
have withdrawn his request
and
the
resolution
establishing this to be the
.........................
‫نغبٚخ‬
ٔ
.....................
‫طبنخ يُز ربسٚخ‬
..........................
:
‫طبدس يٍ لجم‬
case shall be notified to him.
Applications shall be decided
on within 15 calendar days
‫ٍ غ‬
ُ‫ٛض ش‬
‫انزبسٚخ انًمشس نذخٕل د‬
-
29
ٍ
‫ُغ‬
‫انزبسٚخ انًمشس نًغبدسح دٛض ش‬
-
30
29. Intended date of arrival
30. Intended date of departure
of the date of the lodging of
in the Schengen area
from the Schengen area
an application. That period
may be extended up to a
maximum of 30 calendar
days in individual cases,
notably
when
further
‫انهمت نهشخض أٔ األشخبص انزٍٚ لذيٕا انذػٕح فٙ انذٔل األػؼبء‬
-
31
*
* 31. Surname and first name of the inviting person(s)
scrutiny of the application is
‫ٙ دبل غٛش رنك، اسى انفُذق أٔ انفُبدق أٔ أيبكٍ انًُبيخ انًؤلزخ فٙ انذٔل األػؼبء‬
‫ف‬
in the Member State(s). If not applicable, name of hotel(s) or
needed
or
in
cases
of
temporary accommodation(s) in the Member State(s)
representation
where
the
authorities
of
the
represented Member State
are consulted. Exceptionally,
when
additional
documentation is needed in
specific cases, the period
may be extended up to a
maximum of 60 calendar
days.
ٔ‫أ‬
‫النكزشَٔٙ نهشخض‬
‫انؼُٕاٌ انجشٚذ٘ ٔ انؼُٕاٌ ا‬
Telephone and telefax ‫سلى انٓبرف ٔ انفبكس‬
Address and e-mail address of inviting person(s)
The visa once granted must
ٌ‫أٔ انًكب‬
‫شخبص انزٍٚ لذيٕا انذػٕح أٔ انفُذق أٔ انفُبدق‬
‫األ‬
/hotel(s)/temporary accommodation(s)
be collected within a month.
‫خ‬
‫أٔ األيبكٍ نإللبيخ انًؤلز‬
If a visa is not collected
within the aforesaid period,
the
applicant
shall
be
deemed to have renounced to
the visa granted and the
proceedings shall be filed.
* The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to
free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields no 34 and 35.
‫انهزٍٚ لذ ٚسبفشٔا يسخعًهٍٛ حمٓى ببنخجٕال انحش نٛس عهٛٓى‬
)
‫ُب يُّ ٔ يخكفم بٓى‬
‫األصٔاج، األٔالد أٔ األلشببء األكبش س‬
(
٘‫ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش‬
*
33
ٔ
33
‫بئت انحمهٍٛ سلى‬
‫عهٗ ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش٘ حمذٚى انًسخُذاث انز٘ حثبج ْزِ انمشابت ٔ حع‬
.
‫حعبئت انفشاغبث انًؤششة بُجًت‬
‫اسى ٔ ػُٕاٌ انششكخ أٔ انًُظًخ انذاػٛخ‬
-
32
*
‫سلى انٓبرف‬
*32. Name and address of inviting
Telephone and telefax
ٍ‫بعذ حمذٚى انطهب ٚعبد نهطبنب َسخت ي‬
‫ٔ انفبكس‬
ompany/organisation
of company/organisation
‫نهششكخ أٔ انًُظًخ‬
ٔ ‫االسخًبسة يخخٕيت يع ححذٚذ حبسٚخ‬
.
‫يكبٌ االسخالو‬
‫ًٚكٍ أٌ ٚخفك يع انًخمذو عٍ ٔسٛهت‬
‫عًم انطهببث ٔ انخعذٚم ٔ حمذٚى‬
٘‫األنمبة ٔ االسى ٔ انؼُٕاٌ ٔ أسلبو انٓبرف ٔ انفبكس ٔ انؼُٕاٌ انجشٚذ‬
Surname, first name, address, telephone, telefax, and e-mail address
‫انًسخُذاث ٔ انشٓبداث انًطهٕبت ٔ كزا‬
‫نهشخض انًذذد نهزٕاطم فٙ انششكخ أٔ انًُظًخ‬
َٙٔ‫ٔ االنكزش‬
of contact person in company/organisation
ٔ ‫يٕاعٛذ انحضٕس‬
‫ذ‬
ٚ‫ببنُسبت نخحذ‬
.
‫انخبهٛغبث ببنمشاس‬
‫خبهٛغبث ٔ طهب انحضٕس ٚخى عبش‬
‫إٌ ان‬
‫انٓبحف أٔ انفبكس انًمذو نٓزا انغشض‬
:
‫ٔ اإلػبشخ خالل اإللبيخ رغطٗ يٍ لجم‬
‫يظبسٚف انسفش‬
-
33
*
*33. Cost of travelling and living during the applicant's stay is covered
ّ‫يٍ لبم صبحب انعاللت أٔ ٔكٛه‬
‫فٙ حبل عذو حهبٛت انُذاءاث‬
.
ََٕٙ‫انمب‬
‫سخشسم خطٛب إنٗ عُٕاَّ انًحذد‬
ًٍ‫ببنطهب ٔ انز٘ ٚجب أٌ ٚكٌٕ ض‬
□ by the applicant himself/herself
‫انًزمذو‬
□ by a sponsor (host, company,
َّٕ‫دذد فٙ دبل ك‬
(
ٙ‫يٍ لجم انشاػ‬
.
ٙ‫انُطبق انمُصه‬
)
‫ظًخ‬
ُ‫داػٛب أٔ ششكخ أٔ ي‬
organisation), please specify
□ referred to in field 31 or 32
32
ٔ
31
‫انًشبس إنّٛ فٙ انذمهٍٛ سلى‬
ٌ‫انخبهٛغ أٔ االسخذعبء انًشسم ٚجب أ‬
□ other (please specify)
)
‫ٚشجٗ انزذذٚذ‬
(
‫أخش‬
‫أٚبو، ببسخثُبء‬
11
‫ب‬
ْ‫ٚهبٗ فٙ يذة ألصب‬
‫يٕاسد انًؼٛشخ‬
‫يٕاسد انًؼٛشخ‬
‫طهب انًثٕل شخصٛب، فٙ ْزِ انحبنت‬
Means of support
Means of support
‫ٕٚيب‬
13
ٌٕ‫انًذة سخك‬
□ Cash
‫□ َمذا‬
□ Cash
‫□ َمذا‬
□ Traveller's cheques
‫□ شٛكبد سٛبدٛخ‬
□ Accommodation provided
‫□ انسكٍ يمذو نطبنت انزؤشٛشح‬
‫فٙ حبل اسخُفبر إيكبَٛبث انخبهٛغ ٚسبس‬
□ Credit card
‫بَٛخ‬
ً‫ثطبلخ ائز‬
□ Credit card
‫خ‬
َٛ‫ب‬
ً‫ثطبلخ ائز‬
□ Pre-paid accommodation
‫□ انسكٍ يذفٕع يسجمب‬
□ All expenses covered during the stay
‫□ يظبسٚف اإللبيخ كبفخ يغطبح‬
ٙ‫أٚبو ف‬
11
‫إنٗ اإلعالٌ عُّ خالل‬
□ Pre-paid transport
‫□ انًٕاطالد يذفٕػخ يسجمب‬
□ Pre-paid transport
‫□ انًٕاطالد يذفٕػخ يسجمب‬
‫نهًكخب‬
‫انخببعت‬
‫اإلعالَبث‬
‫نٕحت‬
□ Other (please specify)
)
‫ٚشجٗ انزذذٚذ‬
(
‫أخش‬
□ Other (please specify)
)
‫ٚشجٗ انزذذٚذ‬
(
‫أخش‬
.
ٙ‫انمُصه‬
ٔ‫انًؼهٕيبد انشخظٛخ نهمشٚت انز٘ ْٕ يٕاؽٍ يٍ االرذبد األٔسٔثٙ أ‬
-
34
34. Personal data of the family member who is an
.
٘‫األٔسٔثٙ أٔ االرذبد انسٕٚسش‬
٘‫يٍ انذٛض االلزظبد‬
EU, EEA or CH citizen
‫فٙ حبل عذو انخهبٛت فٙ انًٓهت انًحذدة‬
‫نهطهببث أٔ انخبهٛغبث فبَّ سٛعخبش طبنب‬
‫انخأشٛشة يسخُكفب، ٔ سٛخى إعالَّ بمشاس‬
‫نهمت‬
‫ا‬
‫االسى‬
Surname
First name(s)
.
‫االسخُكبف‬
ِ‫إٌ انمشاس بشأٌ انطهببث سٛخى احخبر‬
‫ٕٚيب طبٛعٛب يٍ حبسٚخ حمذٚى‬
13
‫خالل‬
‫ربسٚخ انًٛالد‬
‫ انجُسٛخ‬Number of travel
‫سلى ٔصٛمخ انسفش‬
Date of birth
Nationality
ٗ‫ٔ ًٚكٍ حًذٚذ انًذة إن‬
.
ّ‫انطهب ٔ لبٕن‬
‫أٔ ثطبلخ انٕٓٚخ‬
document or ID card
ٔ ‫ٕٚيب طبٛعٛب فٙ حبالث يعُٛت‬
31
‫خصٕصب عُذيب ٚكٌٕ ضشٔسٚب عًم‬
‫فحص يفصم نهطهب أٔ فٙ حبل إَببت‬
ٙ‫ثٙ أٔ انذٛض االلزظبد٘ األٔسٔث‬
ٔ‫رذبد األٔس‬
‫اإل‬
ٍ‫يٕاؽ‬
‫طهخ انمشاثخ يغ‬
-
35
35. Family relationship with an EU, EEA or CH citizen
‫ٛم أٔ حٕكٛم ٚطهب فٛٓب اسخشبسة‬
‫أٔ حًث‬
٘‫أٔ االرذبد انسٕٚسش‬
ٔ
.
‫جٓبث نذٖ انذٔنت انعضٕ انًًثهت‬
□ spouse
‫صٔجخ‬
/
‫صٔط‬
‫بشكم اسخثُبئٙ، ٔ فٙ حبالث يحذدة‬
□ child
‫اثُخ‬
/
ٍ‫اث‬
ِ‫ٚشخشط فٛٓب يسخُذاث إضبفٛت فبٌ ْز‬
□ grandchild
‫دفٛذح‬
/
‫دفٛذ‬
□ dependent ascendant
ّ‫األلشثبء األكجش سُب يُّ ٔ ػهٗ كفبنز‬
01
‫انًذة ًٚكٍ حًذٚذْب نًذة ألصبْب‬
.
‫ٕٚيب طبٛعٛب‬
‫انًكبٌ ٔ انزبسٚخ‬
-
36
‫فٙ دبل‬
(
‫انزٕلٛغ‬
-
37
36. Place and date
37. Signature (for minors, signature
)
ِ‫انمظش، رٕلٛغ ٔنٙ أيش‬
of parental authority/legal guardian)
ٌ‫ٔ إٌ انخأشٛشة انًٕافك عهٛٓب ٚجب أ‬
‫حؤخز خالل يٓهت شٓش ٔ فٙ حبل عذو‬
َّ‫خالل انًٓهت انًزكٕسة، فب‬
‫انمٛبو بزنك‬
‫سٛفٓى أٌ صبحب انعاللت لذ اسخُكف‬
‫إَُٙ ػهٗ اؽالع ثبٌ سفغ انزؤشٛشح ال ٚؼُٙ إػبدح يظبسٚف يؼبيهخ انزؤشٛشح‬
I am aware that the visa fee is not refunded if the visa is refused.
‫عٍ انخأشٛشة انًًُٕحت ٔ سٛخى حفظ‬
)
24
‫اَظش انذمم سلى‬
(
‫ثبنُسجخ نهًزمذو ثطهت رؤشٛشح يزؼذدح‬
Applicable in case a multiple-entry visa is applied for (cf. field no 24):
.
‫انًهف‬
‫إَُٙ ػهٗ دساٚخ ثؤَُٙ أدزبط نزؤيٍٛ ؽجٙ يُبست خالل انسفشح‬
I am aware of the need to have an adequate travel medical insurance for
.
‫األٔنٗ ٔ نهسفشاد انالدمخ إنٗ أساػٙ انذٔل األػؼبء‬
my first stay and any subsequent visits to the territory of Member States.
* The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right
to free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields no 34 and 35.
‫انهزٍٚ لذ ٚسبفشٔا يسخعًهٍٛ حمٓى ببنخجٕال انحش نٛس عهٛٓى‬
)
‫األصٔاج، األٔالد أٔ األلشببء األكبش سُب يُّ ٔ يخكفم بٓى‬
(
٘‫بد انسٕٚسش‬
‫ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االحح‬
*
33
ٔ
33
‫ث انز٘ حثبج ْزِ انمشابت ٔ حعبئت انحمهٍٛ سلى‬
‫عهٗ ألشببء يٕاطُٕ االححبد األٔسٔبٙ ٔ انُطبق االلخصبد٘ األٔسٔبٙ أٔ االححبد انسٕٚسش٘ حمذٚى انًسخُذا‬
.
‫حعبئت انفشاغبث انًؤششة بُجًت‬
I am aware of and consent to the following: the collection of the data required by this application form and the taking of my
photograph and, if applicable, the taking of fingerprints, are mandatory for the examination of the visa application; and any
personal data concerning me which appear on the visa application form, as well as my fingerprints and my photograph will be
supplied to the relevant authorities of the Member States and processed by those authorities, for the purposes of a decision on
my visa application.
Such data as well as data concerning the decision taken on my application or a decision whether to annul, revoke or extend a
1
visa issued will be entered into, and stored in the Visa Information System (VIS)
for a maximum period of five years, during
which it will be accessible to the visa authorities and the authorities competent for carrying out checks on visas at external
borders and within the Member States, immigration and asylum authorities in the Member States for the purposes of
verifying whether the conditions for the legal entry into, stay and residence on the territory of the Member States are fulfilled,
of identifying persons who do not or who no longer fulfil these conditions, of examining an asylum application and of
determining responsibility for such examination. Under certain conditions the data will be also available to designated
authorities of the Member States and to Europol for the purpose of the prevention, detection and investigation of terrorist
offences and of other serious criminal offences. The authority of Member State responsible for processing the data is: FPS
Foreign Affairs, Foreign Trade and Development Cooperation rue des Petits Carmes 15 1000 Brussels Belgium.
I am aware that I have the right to obtain in any of the Member States notification of the data relating to me recorded in the
VIS and of the Member State 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 deleted. At my express request, the authority examining 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 corrected or deleted, including the related remedies according to the national law of the State concerned. The national
supervisory authority of that Member State [Commission for the Protection of Privacy-139, rue Haute, 1000 Brussels] will
hear claims concerning the protection of personal data.
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 law of the Member State which deals with the application.
I undertake to leave the territory of the Member States before 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 Member 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 Article 5(1) of Regulation (EC) No 562/2006 (Schengen Borders Code) and I am therefore refused entry. The
prerequisites for entry will be checked again on entry into the European territory of the Member States.
ٔ ‫أخز انًؼهٕيبد انًطهٕثخ فٙ ْزِ االسزًبسح، أخز طٕسح شخظٛخ نٙ ٔ إٌ نضو أخز ثظًبرٙ، دٛش كم رنك إنضايٛب نذساسخ‬
:
ٙ‫إَُٙ ػهٗ ػهى ثًب ٚهٙ ٔ يٕافك فّٛ ػهٗ يب ٚه‬
‫انجٓبد انًخزظخ نهذٔنخ‬
ٗ‫فذض ؽهت انزؤشٛشح، ٔ أٌ يؼهٕيبرٙ انشخظٛخ ٔ انًذَٔخ فٙ اسزًبسح ؽهت انزؤشٛشح ٔ كزا ثبنُسجخ ثظًبرٙ ٔ طٕسرٙ سٛسبس إنٗ رجهٛغٓب إن‬
.
‫انؼؼٕ ٔ سٛزى يؼبنجزٓب يٍ لجم رهك انجٓبد نغشع ارخبر انمشاس ثشؤٌ ؽهجٙ نهزؤشٛشح‬
‫ٔ رخضُٚٓب فٙ َظبو انزؤشٛشاد‬
‫ٔ إٌ ْزِ انًؼهٕيبد ٔ كزا انمشاس انز٘ سٛزخز ثشؤٌ ؽهجٙ أٔ انمشاس انخبص ثئنغبء ٔ سذت ٔ رًذٚذ انزؤشٛشح انًًُٕدخ سٛسبس إنٗ إدخبنٓب‬
ٙ‫ًٚكٍ انٕطٕل إنٛٓب يٍ لجم انجٓبد انًخزظخ ثغٛخ ػجؾ انزؤشٛشاد ػُذ انذذٔد انخبسجٛخ ٔ فٙ انذٔل األػؼبء ٔ جٓبد انٓجشح ٔ انهجٕء ف‬
ٔ ،‫سُٕاد‬
5
‫خالل فزشح‬
)
( 1
‫ش انًسزكًهٍٛ نٓب أٔ نى‬
ٛ‫خبص غ‬
‫انذٔل األػؼبء ثمظذ انزذمك يٍ أَٓب يسزكًهخ نششٔؽ انذخٕل ٔ انزٕاجذ ٔ اإللبيخ انمبََٕٛخ فٙ أساػٙ انذٔل األػؼبء ٔ انزؼشف ػهٗ األش‬
‫فٙ دبالد يؼُٛخ ًٚكٍ أٚؼب انشجٕع إنٗ انًؼهٕيبد انًذَٔخ يٍ لجم‬
.
‫ٚسزٕفٕا ْزِ انششٔؽ ٔ كزا ثبنُسجخ نذساسخ ؽهجبد انهجٕء ٔ رذذٚذ انًسؤٔنٛخ ػٍ ْزِ انذساسخ‬
ِ‫ٔ أٌ انجٓخ انًسئٕنخ ػٍ يؼبنجخ ْز‬
.
ٖ‫خ إسْبثٛخ ٔ جشائى خطٛشح أخش‬
ُ‫انجٓبد انًسئٕنخ ثبنذٔل األػؼبء ٔ انششؽخ األٔسٔثٛخ ثغٛخ انزفبد٘ ٔ انكشف ٔ انجذش ػٍ ج‬
.
‫ثهجٛكب‬
-
‫ثشٔكسم‬
‫شبسع‬
،
ٙ‫انزجبسح انخبسجٛخ ٔانزؼبٌٔ اإلًَبئ‬
،
‫لٕح دًبٚخ انًُشآد‬
ٌٕ‫سٛك‬
‫انًؼهٕيبد كًب ْٕ انذبل ثبنُست حنجهجٛكب‬
15 1000
Petits Carmes
‫دٔنخ ػؼٕا انمٛبو ثئػاليٙ ثبنًؼهٕيبد انزٙ رخظُٙ ٔانًذخهخ فٙ َظبو انزؤشٛشاد ٔ يٍ انذٔنخ انؼؼٕ انزٙ لبيذ ثُمهٓب ٔأٚؼب‬
‫ٔأَّ صبثذ نذ٘ ثؤَّ ٚذك نٙ أٌ أؽهت يٍ أٚخ‬
‫ظب‬
ٛ‫ٔفٙ دبل ؽهت رنك خظ‬
.
ََٕٙ‫انمٛبو ثطهت رؼذٚم رهك انًؼهٕيبد انشخظٛخ غٛش انذلٛمخ ٔشطت انًؼهٕيبد انزٙ رخض شخظٙ ٔانزٙ جشٖ انزؼبيم يؼٓب ثشكم غٛش لب‬
‫ٔ انمٛبو ثزؼذٚهٓب أٔ إنغبئٓب‬
ُٙ‫فئٌ انجٓبد انزٙ رمٕو ثذساسخ ؽهجٙ سزؼهًُٙ ثبنطشٚمخ انزٙ ًٚكُُٙ يٍ خالنٓب يًبسسخ دمٙ فٙ انزذمك يٍ انًؼهٕيبد انشخظٛخ انزٙ رخظ‬
‫شبسع‬
،
139
‫نجُخ نذًبٚخ انخظٕطٛخ‬
ٙٓ‫ف‬
‫ثهجٛكب‬
‫فٙ دبل‬
(
‫ٔ دٕل ؽشق رمذٚى انطؼٌٕ انزٙ ٚزؼًُٓب انمبٌَٕ انًذهٙ نهذٔنخ انًؼُٛخ ٔ انجٓبد انٕؽُٛخ انًششفخ‬
Haute
.
‫سزمٕو ثزهجٛخ انشكبٖٔ انزٙ رخض دًبٚخ انًؼهٕيبد انشخظٛخ‬
)
‫ثشٔكسم‬
1000
ٔ‫ب نشفغ ؽهجٙ أ‬
‫ٔ إَُٙ ػهٗ ػهى ثبٌ كبفخ األلٕال غٛش انظذٛذخ ًٚكٍ أٌ ركٌٕ سجج‬
.
‫ٔ إَُٙ أطشح دست ظُٙ ثبٌ كبفخ انًؼهٕيبد انًمذيخ يٍ لجهٙ ْٙ طذٛذخ ٔ كبيهخ‬
.
‫إنغبء انزؤشٛشح انزٙ يُذذ نٙ ٔ ًٚكٍ انزمبػٙ ػذ٘ شخظٛب ؽجمب نزششٚغ انذٔنخ انؼؼٕ انزٙ لبيذ ثمجٕل ؽهجٙ نإلجشاء‬
‫ل ألساػٙ أٔسٔثب انزبثؼخ‬
ٕ‫ٔ لذ جشٖ إػاليٙ ثبٌ دٛبصح رؤشٛشح نٛس ْٕ انششؽ انٕدٛذ نهذخ‬
.
ٙ‫ٔ إَُٙ أرؼٓذ ثًغبدسح أساػٙ انذٔل األػؼبء لجم اَزٓبء انزؤشٛشح انزٙ رًُخ ن‬
‫لبٌَٕ دذٔد‬
(
2006
/
562
:
‫، يٍ َظبو انًجًٕػخ األٔسٔثٛخ سلى‬
1
‫نهذٔل األػؼبء ٔ أٌ يُذٙ رؤشٛشح ال ٚؼُٙ اَّ نذ٘ انذك ثزؼٕٚغ نٕ خبنفذ ثُٕد انًبدح انخبيسخ، انفمشح‬
.
‫نذٔل األػؼبء‬
‫إٌ اسزكًبل ششٔؽ انذخٕل سٛزى انزذمك يُّ ػُذ دخٕل أساػٙ ا‬
.
ٙ‫ٔ ٚشفغ نزنك دخٕن‬
)
ٍ‫شُف‬
‫انًكبٌ ٔ انزبسٚخ‬
)
‫رٕلٛغ ٔنٙ األيش ثبنُسجخ نهمظش‬
(
‫انزٕلٛغ‬
Place and date
Signature (for minors, signature of
parental authority/legal guardian):
1
‫لذس يب ٚسًخ ثّ ػًم َظبو انزؤشٛشاد‬
)
( 1
In so far as the VIS is operational
.

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