"Italy National (D) Visa Application Form - Consulate General of Italy" - Los Angeles, California

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Consulate General of Italy - Los Angeles
PHOTOGRAPH
National (D) visa application form
This form is free of charge
.................................................
1. Surname (Family name)/ (x)
...........................................
For official use only
2. Surname at birth (Former family name(s)) / (x)
Data della domanda:
3. First name(s) / (x)
4. Date of birth (day-month-year)
5. Place of birth
7. Current nationality
Numero della domanda di
visto:
6. Country of birth
Nationality at birth, if different
Domanda presentata presso:
Ambasciata/Consolato
Centro comune
8. Sex:
9. Marital status:
Fornitore di servizi
Intermediario commerciale
Male
Single
Married
Altro
Female.
Separated
Divorced
Widow(er)
Nome:
Other (please specify)
10. For minors: surname, first name, address (if different from the applicant’s) and nationality of parental authority/legal
guardian:
Responsabile della pratica:
Nome di chi ha ricevuto la
11. National identity number, where applicable:
pratica allo sportello:
12. Type of travel document:
Ordinary passport
Diplomatic passport
Documenti giustificativi:
Service passport.
Official passport
Documento di viaggio
Special passport
Mezzi di sussistenza
Other travel document (please specify):
Invito
15. Valid until (day-month-yr) 16. Issued by
13. Numer of travel
14. Date of issue.(day-month-
Mezzi di trasporto
document
yr)
Assicurazione sanitaria di
viaggio
Altro
17. Appplicant’s home address and e-mail address
Telephone number(s)
......................................
Decisione relativa al visto:
Rifiutato
Rifiutato per segnalazione
18. Are you residing in a country other than the country of your current nationality:
SIS non cancellabile.
N o
Pratica Sospesa
Yes. Residence permit or equivalent:.....................: ………………N.………………………. Valid until …………………..
Rilasciato
Tipo di visto:
19. Current occupation
D
20. Employer, employer’s address and telephone number. For students, name and address of educational institution.
Valido:
dal …………………………..
1
Consulate General of Italy - Los Angeles
PHOTOGRAPH
National (D) visa application form
This form is free of charge
.................................................
1. Surname (Family name)/ (x)
...........................................
For official use only
2. Surname at birth (Former family name(s)) / (x)
Data della domanda:
3. First name(s) / (x)
4. Date of birth (day-month-year)
5. Place of birth
7. Current nationality
Numero della domanda di
visto:
6. Country of birth
Nationality at birth, if different
Domanda presentata presso:
Ambasciata/Consolato
Centro comune
8. Sex:
9. Marital status:
Fornitore di servizi
Intermediario commerciale
Male
Single
Married
Altro
Female.
Separated
Divorced
Widow(er)
Nome:
Other (please specify)
10. For minors: surname, first name, address (if different from the applicant’s) and nationality of parental authority/legal
guardian:
Responsabile della pratica:
Nome di chi ha ricevuto la
11. National identity number, where applicable:
pratica allo sportello:
12. Type of travel document:
Ordinary passport
Diplomatic passport
Documenti giustificativi:
Service passport.
Official passport
Documento di viaggio
Special passport
Mezzi di sussistenza
Other travel document (please specify):
Invito
15. Valid until (day-month-yr) 16. Issued by
13. Numer of travel
14. Date of issue.(day-month-
Mezzi di trasporto
document
yr)
Assicurazione sanitaria di
viaggio
Altro
17. Appplicant’s home address and e-mail address
Telephone number(s)
......................................
Decisione relativa al visto:
Rifiutato
Rifiutato per segnalazione
18. Are you residing in a country other than the country of your current nationality:
SIS non cancellabile.
N o
Pratica Sospesa
Yes. Residence permit or equivalent:.....................: ………………N.………………………. Valid until …………………..
Rilasciato
Tipo di visto:
19. Current occupation
D
20. Employer, employer’s address and telephone number. For students, name and address of educational institution.
Valido:
dal …………………………..
1
21. Purpose of travel:
al…………………………….
Joining family member/ Accompanying family member
Numero di ingressi:
Religious activity
Sport
Mission
Diplomatic
1
Medical reasons
Study
Adoption
Subordinate work
2
Autonomous work
Other (specify)/.....................................…………………………….
Multipli
(x) Provide the information as indicated in the travel document.
22. City of destination
23. Schengen country of first entry
Numero di giorni:
……………………………….
24. Number of entries requested:
25. Duration of stay. Indicate the number of days
(max. 365 days)
O n e
T wo
Multiple.
26. Schengen visas issued in the past three years:
No n e
Yes. Date(s) of validity: from ...…………………………….. to.. ………………………………. …
27. Fingerprints previously taken for a Schengen visa application:
Finger
No
Yes. Indicate date if known:……………………………………………….
28. Number of the Nullaosta issued for a Joining family member visa/Accompanying family member visa/
Subordinate work visa (only when required by the regulations governing the type of visa requested)……………….
Issued by the SUI of the city of ……………………………………. Valid from ………………….until………………..
29. Intended date of arrival in the Schengen area
30. Intended date of departure from the Schengen area
(only for visas valid from 91days to 364 days)
31. Name of the person who requested the family reunion visa, or the name of the employer. Indicate your address
in Italy, if it is visa for Adoption, Religious Activities, Medical Reasons, Sport, Study, Mission.
Telephone number and fax number of the person(s)
Address and e-mail address of the person(s) who requested
who requested the family reunion visa, or the name of
the family reunion visa, or the name of the employer.
the employer.
32. Name and address of the inviting company/
Telephone number and fax number of the company/
organization..
organization.
Name, address, telephone number, fax number and e-mail address of the contact person of the company/
organization.
33. The applicant’s expenses for travel and stay are the responsibility of:
the applicant.
of the sponsor (host, company, organization),
specify:……………………………………………
…………………………………………………..
Means of support:
referred to in field n. 31 or 32.
Cash
Traveller's cheques
other (specify)..........................:…………………
Credit cards
Prepaid accomodation
Means of support:
Prepaid transportation
Other (specify)………………………….
Cash
Accommodation provided
INFORMATION NOT NECESSARY FOR THE
All expenses covered during the stay..
FOLLOWING VISAS:
Prepaid transportation
Joining Family Member, Accompanying Family Member,
Other (specify) ………………………………..
Subordinate Work,Autonomous Work, Mission, Diplomatic,
Adoption.
2
34. Personal data of the family member who is a citizent of the EU, EEA or CH:
Surname (family name).
First name(s)
Date of birth
Nationality
Number of travel document or ID card
35. Family relationship with a EU, EEA or CH citizen:
spouse
son/daughter
other direct ascendant –grandchild
dependent ascendant
36. Place
37. Signature
(Signature of parent or legal guardian if applicant is a
minor)
Date
.............................................................................................................................................................................
...........................................................................................................................................
I am aware that the handling visa fee is not refunded if the visa is refused.
am aware of and consent to the following: that the collection of the data required by this application, the taking of my
I
photograph and, if applicable, the taking of my fingerprints are mandatory for the examination of the visa application, and that
the personal data concerning me which appears on the visa application form, as well as my fingerprints and my photograph will
be supplied to the relevant Italian authorities and processed by those authorities for the purpose of a decision on my visa
application.
Such data, as well data concerning the decision taken on my application or a decision whether to annul or revoke an issued visa
will be entered into and stored in the visa information system of the Italian Embassy/Consulate and of the Italian Ministry of
Foreign Affaire.
Such data will be accessible to the national authorities responsible for visas. Furthermore, such data will be accessible to the
Schengen authorities competent for carrying out checks on visas at external borders, to the immigration and asylum authorities
of the Member States (for the purpose of verifying whether the conditions for the legal entry into, the stay and residence on the
territory of the Member States are fulfilled, of identifying persons who do not or no longer fulfil these conditions), to the
authorities of the Member States responsible for examining of an asylum application. Under certain conditions the data will also
be available to designated authorities of the Member States and to Europol for the purpose of the prevention, detection and
investigation of terrorist offences and other serious criminal offences.
I am aware that I have the right to obtain notification of the data relating to me recorded in the visa information system, and the
right to request that inaccurate data relating to me be corrected and that data relating to me processed unlawfully be deleted. At
myrequest, the authority examining my application will inform me of the manner in which I may exercise my right to verify my
personal data, and have them corrected or deleted, including the related remedies according to the national legislation. The
responsible national authority is the “Garante per la Protezione dei Dati Personali”.
I declare that all the data provided by me are complete and correct. I am aware that 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
Italian Representative (article 331 c.p.p.).
The mere fact that a visa has been granted does not mean that I will be entitled to compensation if I fail to comply with the
relevant provisions of Article 5, paragraph 1 of Regulation EU n. 562/2006 (Schengen Borders Code) and of Article 4 of Italian
Law 286/98 and for said reasons I will be refused entry.
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riservato all’Ufficio)
ANNOTAZIONI (
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Place
Signature
(Signature of parent or legal guardian if applicant is a minor)
Date
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