Sample "Italian Application Form for National Visa (D) - Consulate General of Italy, Boston, Massachusetts, Usa" - Boston, Massachusetts

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Download Sample "Italian Application Form for National Visa (D) - Consulate General of Italy, Boston, Massachusetts, Usa" - Boston, Massachusetts

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!!
C
Consulate General of Italy
Photo
.
Boston
A pplication for National V isa (D)
T his application form is free
...............................................
.................................................
1. Surname (s) (family name(s) ) (x)
...........................................
Y O U R L AST N A M E E X A C T L Y AS I T A PP E A RS O N Y O U R P ASSPO R T
F O R E M B ASSY
2. Surname(s) at birth (former family name(s)) (x)
/C O NSU L A T E USE O N L Y
M A I D E N N A M E I F A PP L I C A B L E O T H E R W ISE L E A V E B L A N K
3. F irst names (given names) (x)
Date of application:
F I RST A N D M I D D L E N A M E E X A C T L Y AS I T A PPE A RS O N Y O U R P ASSP O R T
4. Date of birth (day-month-year)
5. Place of birth/.................
7. C u r r ent nationality
......................................
C I T Y A N D ST A T E O F
V isa application number :
E X A M PL E : M A R C H 24, 1991
BIR T H
U.S. A N D/ O R O T H E R N A T I O N A L I T Y
SH O U L D APPE A R 24 03 - 1991
Nationality at bi rth, if different:
6. C ount r y of bi r th/........................
A pplication lodged at:
............................................................
C O U N T R Y O F B I R T H
D O N O T
U .S. A N D/ O R O T H E R N A T I O N A L I T Y
E mbassy/Consulate
A B B R E V I A T E
C ity hall C A C
8. Sex
9. M arital status
Service provider
C H E C K A PP R O P R I A T E B O X
Commercial Intermediary
M ale
Single
M a r r ied
O ther
F em ale
Sep a r ated
D ivor ced
W idow/er
Name:
C H E C K A PP R O P R I A T E B O X
O the r (please specify)
10. In the case of minors: Surname, fi rst name, addr ess (if different from applicant ) and nationality of pa rent al authority/
legal gua rdian/......................................... ...............................
F ile handled by:
I F A PPL I C A B L E , C O M P L E T E AS I NST R U C T E D
Name of person who received
11. N ational I dentity number , whe re applicable/......................................................................
L E A V E T H IS B L A N K
file at window:
12. T ype of t r avel documen t/................................................
You can find this
O r din a r y p asspor t
D iplom atic p asspor t
in your passport
Supporting documents:
stated under
Se r vice p asspor t
O fficial p asspor t
T ravel document
A uthority
Special passport.
Means of substance
O ther t r avel document (please specify)
C H E C K O R D I N A R Y P ASSP O R T
I nvitation
16. Issued by
13. N umbe r of t r avel
14. D ate of issue
15. V alid until
Means of transport
L IST T H E PL A C E
document
D A Y-M O N T H-Y E A R
D A Y-M O N T H-Y E A R
(COUNTRY)
T ravel H ealth insurance
Y O U R P ASSP O R T W AS
Y O U R P ASSP O R T IS
W H E R E Y O U R
O ther
P ASSP O R T N U M B E R
P ASSP O R T W AS ISSU E D
ISSU E D
V A L I D U N T I L
T elephone number (s)
17.
-m ail ad d r ess
V isa decision:
...............................................................
Refused
B EST C O N T A C T N U M B E R I N C L.
Y O U R C O M P L E T E H O M E A D D R ESS A N D E M A I L A D D R ESS
Refused for SIS non
A R E A C O D E
cancellable.
18. R esidence in a count r y othe r than the count r y of cu r r ent nationality /.....................................
Suspended F ile
N o
Issued
C H E C K
N O
U N L E S S Y O U A R E L I V I N G I N A C O U N T R Y O T H E R T H A N Y O U R H O M E C O U N T R Y
Y es. R esidence pe r m it or eq u ivalen t / ................................ N o
V alid until
T ype of visa:
19. C ur rent occupation
D
W R I T E ST U D E N T
V alid:
. F or students, n ame and ad d r ess of ed ucation al
20.
establish m en t.
L I S T T H E U .S. S C H O O L Y O U A R E A T T E N D I N G W I T H C O M P L E T E A D D R E SS
from
................................................ ................................................ ........................... .....................
until
21. M ain Purpose(s) of the journey/.........................................................
C H E C K ST U D Y
Number of entries:
F amily reunion/V isiting F amily
1
Religious
Sports
B usiness
D iplomatic
2
M ultiplie
M edical treatment
Study
A doption
E mployment
Self employment
O ther (please specify)
(x) In fields from 1 to 3 information must be inserted as it appears on travel documents.
Numero di giorni:
1
!
!!
C
Consulate General of Italy
Photo
.
Boston
A pplication for National V isa (D)
T his application form is free
...............................................
.................................................
1. Surname (s) (family name(s) ) (x)
...........................................
Y O U R L AST N A M E E X A C T L Y AS I T A PP E A RS O N Y O U R P ASSPO R T
F O R E M B ASSY
2. Surname(s) at birth (former family name(s)) (x)
/C O NSU L A T E USE O N L Y
M A I D E N N A M E I F A PP L I C A B L E O T H E R W ISE L E A V E B L A N K
3. F irst names (given names) (x)
Date of application:
F I RST A N D M I D D L E N A M E E X A C T L Y AS I T A PPE A RS O N Y O U R P ASSP O R T
4. Date of birth (day-month-year)
5. Place of birth/.................
7. C u r r ent nationality
......................................
C I T Y A N D ST A T E O F
V isa application number :
E X A M PL E : M A R C H 24, 1991
BIR T H
U.S. A N D/ O R O T H E R N A T I O N A L I T Y
SH O U L D APPE A R 24 03 - 1991
Nationality at bi rth, if different:
6. C ount r y of bi r th/........................
A pplication lodged at:
............................................................
C O U N T R Y O F B I R T H
D O N O T
U .S. A N D/ O R O T H E R N A T I O N A L I T Y
E mbassy/Consulate
A B B R E V I A T E
C ity hall C A C
8. Sex
9. M arital status
Service provider
C H E C K A PP R O P R I A T E B O X
Commercial Intermediary
M ale
Single
M a r r ied
O ther
F em ale
Sep a r ated
D ivor ced
W idow/er
Name:
C H E C K A PP R O P R I A T E B O X
O the r (please specify)
10. In the case of minors: Surname, fi rst name, addr ess (if different from applicant ) and nationality of pa rent al authority/
legal gua rdian/......................................... ...............................
F ile handled by:
I F A PPL I C A B L E , C O M P L E T E AS I NST R U C T E D
Name of person who received
11. N ational I dentity number , whe re applicable/......................................................................
L E A V E T H IS B L A N K
file at window:
12. T ype of t r avel documen t/................................................
You can find this
O r din a r y p asspor t
D iplom atic p asspor t
in your passport
Supporting documents:
stated under
Se r vice p asspor t
O fficial p asspor t
T ravel document
A uthority
Special passport.
Means of substance
O ther t r avel document (please specify)
C H E C K O R D I N A R Y P ASSP O R T
I nvitation
16. Issued by
13. N umbe r of t r avel
14. D ate of issue
15. V alid until
Means of transport
L IST T H E PL A C E
document
D A Y-M O N T H-Y E A R
D A Y-M O N T H-Y E A R
(COUNTRY)
T ravel H ealth insurance
Y O U R P ASSP O R T W AS
Y O U R P ASSP O R T IS
W H E R E Y O U R
O ther
P ASSP O R T N U M B E R
P ASSP O R T W AS ISSU E D
ISSU E D
V A L I D U N T I L
T elephone number (s)
17.
-m ail ad d r ess
V isa decision:
...............................................................
Refused
B EST C O N T A C T N U M B E R I N C L.
Y O U R C O M P L E T E H O M E A D D R ESS A N D E M A I L A D D R ESS
Refused for SIS non
A R E A C O D E
cancellable.
18. R esidence in a count r y othe r than the count r y of cu r r ent nationality /.....................................
Suspended F ile
N o
Issued
C H E C K
N O
U N L E S S Y O U A R E L I V I N G I N A C O U N T R Y O T H E R T H A N Y O U R H O M E C O U N T R Y
Y es. R esidence pe r m it or eq u ivalen t / ................................ N o
V alid until
T ype of visa:
19. C ur rent occupation
D
W R I T E ST U D E N T
V alid:
. F or students, n ame and ad d r ess of ed ucation al
20.
establish m en t.
L I S T T H E U .S. S C H O O L Y O U A R E A T T E N D I N G W I T H C O M P L E T E A D D R E SS
from
................................................ ................................................ ........................... .....................
until
21. M ain Purpose(s) of the journey/.........................................................
C H E C K ST U D Y
Number of entries:
F amily reunion/V isiting F amily
1
Religious
Sports
B usiness
D iplomatic
2
M ultiplie
M edical treatment
Study
A doption
E mployment
Self employment
O ther (please specify)
(x) In fields from 1 to 3 information must be inserted as it appears on travel documents.
Numero di giorni:
1
Count O N L Y the number of
days of the program from
Housing C heck In to
Housing C heck O ut.
22. C ity of destination
23. State of fi rst entr y
E V E N I F Y O U A R E
W R I T E I T A L Y, B O L O G N A
W R I T E C I T Y A N D C O U N T R Y W H E R E Y O U R F I RST
A R R I V I N G A F E W D A YS
F L I G H T L A N DS A F T E R D E P A R T I N G T H E U.S.
B E F O R E O R L E A V I N G A
F E W D A YS A F T E R T H E
24. Number of entries requested/ ...............................:
25. Dur ation of the stay. Indicate number
PR O G R A M. For full year
of days (max. 365 days) /
students, count from
O n e / . .. . . .
T w o/ . .. . . .
M ultiple/.............
.......................................................:
Housing C heck In of the
L IST T H E N U M B E R O F D A YS O F T H E T E R M
first term until the last day
C H E C K M U L T IP L E
of F inal E xams of the
26. Schengen visas issued during the past three years / ......................... ........................:
second term.
N o / . . .
L I S T O T H E R V I S A S O B T A I N E D , O T H E R W I S E , C H E C K
N O
Yes. Date(s) of validity / .............. from/....
to /..
27. F inger pr ints ta ken previously for the pur pose of applying for a Schengen visa
T he Schengen area
................................................ .................... . . .............................................:
includes: A ustria,
C H E C K N O U N L E SS T H IS A PP L I E S T O Y O U
Belgium, Denmar k,
N o/...
Y es/.... Date, if known/......................
F inland, F rance,
Must
Germany, G reece,
match
28. Number of no objection document issued for family reunification/accompanying family/employment (only in
Iceland, Italy,
flight
case where required by legislation gover ning the type of being requested)/ ...........................................................
L uxemburg, T he
itinerary
Issued by SU I of /..........................................
D O E S N O T A PP L Y W R I T E N A
Netherlands, Norway,
V alid f rom/.....................
until/....
Portugal, Spain and
29. Intended date of a r r ival in the Schengen a rea
30. Intended date of depar ture from the Schengen area
Sweden.
......................................................................
(only for visas valid for stays of between 91-364 days)
DD/MM/YYYY
..........................................................
DD/MM/YYYY
A C T U A L D A T E Y O U W I L L A R R I V E
A C T U A L D A T E Y O U W I L L D E PA R T
31. Sur name and first name of the inviting person or employer. If not applicable, in case of visa for A doption,
Religious reasons, M edical reasons, Spor ts, Study, M ission: address of institution in Italy.
...................................................................... .................................... .......... ......................................... .
L IST I NSI T U T I O N I N I T A L Y
B rown in Italy, V ia Belmeloro 7, 40126 Bologna, Italy
Phone: 39-051-2960906
A ddress and e-mail address of inviting person(s) or
T elephone and fax of inviting person(s) or
employer...............................................
employer
................................................................................
32. Name and address of inviting company/organisation
T elephone and fax of company/organisation
/.......................................................
.................................................................
Sur name and first name, address, telephone, fax and e-mail address of contact person in company/organisation/
.......................................................................................................................................................
33. Cost of travelling and living expenses is covered by /.......................................................................:
by the applicant himself/herself/
by sponsor (host, company, organisation),
specify/ ........................................................
..........................................
C H E C K H I MSE L F/ H E RSE L F
Refe r r ed to in field 31 or 32 / .......................
Means of support/..........................................:
othe r (please
C H E C K A L L T H A T APPL Y
specify)/..........................
C ash/ ..............................
T raveller's cheques/................................
C redit ca r d/..................................
Means of support/..............................:
Prepaid accommodation/..........................
Pr epaid tr anspor t/...............................
C ash/....................
O ther (please specify)/...............:..................................
Accommodation provided..................................
A ll expenses covered during the stay/
STATEMENT NOT NECESSARY FOR FOLLOWING
....................................................
VISAS:
Prepaid transport/.....................
Family reunion, Accompanying Family, Employment/Self-
O ther (please specify)/ ..........(..........
employed, Business, Diplomatic, Adoption.
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W R I T E N/ A . I F Y O U A R E A N E U C I T I Z E N C O N T A C T T H E O IP
34. Personal data of the family member who is an E U, SE E or C H citizen / .........................................................................
Surname / ................
F irst name(s) / ......................
Date of birth / ....................
Nationality / .......................
Number of travel document or I D card
..............................................
35. Family relationship with an E U, SE E or C H citizen/ ........................................................................:
spouse/................
child/ ........./..
other direct descendant/............
dependent ascendant/.............................
36. Place and date / ................................
37. Signature (for minors, signature of parental
authority/legal guardian)/ .......... (............................................)
W R I T E B OST O N A N D T H E D A T E D D-M M-Y Y Y Y
SI G N Y O U R N A M E I N B L U E I N K
.............................................................................................................................................................................
...........................................................................................................................................
I am aware that the visa fee is not refunded if the visa is refused.
N/A LEAVE BLANK
........................................................................... ...........................................................................................
I am aware of and consent to the collection of the data required by this application form and the ta king of my photograph and , if applicable, the
ta king of fingerprints. I understand these, are mandatory for the examination of the visa application. A ny 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 Italian authorities 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 visa issued will be
entered, and stored in the Information System of this Consulate G eneral, and the Ministry of Foreign Affairs. Such data will be accessible to the
competent Italian visa authorities. It will be accessible to the competent Schengen authorities in order to check 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 in the territor y 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 also
be accessible to authorities designated by the Member States and to E uropol for the purpose of the prevention, detection and i nvestigation of
ter rorist offenses and of other serious criminal offenses..
I am aware that I have the right to obtain the data transmitted relating to me recorded in the information systems and to request that data
relating to me which are inaccurate be cor rected and that data relating to me processed unlawfully be deleted. A t 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 cor rected or deleted, including the related remedies according to the national law.
T he national controlling A uthority is the G uarantor of protection of personal data.
I declare that to the best of my knowledge all information supplied by me are complete and correct. 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
Representative country under State legislation (articolo 331 c.p.p.).
T he 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 A rticle 5, paragraph 1 of Regulation (E U) No. 562/2006 (Schengen Borders Code) and of A rticle 4 of D. Lgs. 286/98 and I am
therefore refused entry.
A N N O T A T I O NS (
Office use only)
.
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Signatures (for minors, signature of pa rental authority/legal guar dian)
Place and date / .......................
/ ..........................................................................................
WRITE "BOSTON" AND THE DATE DD/MM/YYYY
SIGN YOUR NAME IN BLUE INK
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