Harmonised application form'

Application for Schengen Visa

3a5IBJIeHlIe aa norrynenae IIIeHreHCKOH BlI3bI

PHOTO <l>oTorpaq:m51

This application form is free Becnnarnaa anxera

D Female

D Separated

Surname (Family name) (x) <DaMHJUUI (x)

Surname at birth (Former family name(s)) (x)

<DaMHJIH5I npn poacnenan (rrpel1bII1YlI1a51 / -ne cpaMHJIH5I / -H) (x)

First name(s) (Given name(s)) (x) IIM5I / HMeHa (x)

Date of birth (day-month-year) ,[laTa po)!{,[(eHH5I (nem, - MeC5I11 - rOI1)

)KeHcKHll He rrpoaoraaer C cvnpyroxr

D Other (please specify) IS1l11nortin

~~ __ ~ ~~~ __ ~~ ~_R~~~~~_l~~~~~~ II~H~o~eJ1~~~;L __ ~~~ __ ~~I~

case of minors: Surname, first name, address (if different from applicant's) and nationality of Means of subsistence

authority/legal guardian neconepmeanorrernax: cpaMHJIH5I, HM5I, azipec (eCJIH OTJIHQaeTC5I OT aztpeca 3a5lBHTeAA) H rpa)!{,[(aHCTBO JIHl1a rrOJIHOMOQHeM pOI1HTeJIell /3aKoHHoro rrpel1CTaBHTeAA

Date of issue ,[laTa BbIl1aQH

D Official passport OCPHI1HaJIbHbIll nacnopr

, where applicable

of travel document

Ordinary passport 06bIQHbIll nacnopr Special passport OC06bIll nacnopr

D Diplomatic passport D Service passport

,[IHrrJIOMaTHQeCKHll nacnopr Cny)!(e6HbIll nacnopr

D Other travel document (please specify)

HHOll rrpoe311HOlll10KYMeHT (YKa3aTb xaxoii)

Number of travel document HOMep npoeszmoro 110KYMeHTa

Valid until

home address and e-mail address

Residence in a country other than the country of current nationality Crpana rrpe6bIBaHH5I, eCJIH He 51BAAeTC5I crpanoti rpaactaacrna

NOD Yes. Residence permit or equivalent .

,[Ia. BHI1 na )!(HTeJIbCTBO HJIH paBH0l1eHHbIlll10KYMeHT N2

1

No logo is required for Norway, Iceland and Switzerland.

ER FULL ~~~RSION

19. Current occupation IIpocpeccHoHaJIbHa5ll1e5lTeJIbHocTb B HaCT05llI1ee BpeM5I

~o. Employer and employer's address and telephone number. For students, name and address of
educational establishment.
Pa60T0l1aTeJIb; azipec 1I re.rerpon pario ronarens, ,[IJili cTYl1eHTOB, IIIKOJIbHlIKOB - nasaaaae 1I azipec yqe6HOrO
paneneuaa.
~1. Main purpose(s) of the journey:
OCHOBHa5lI1eJIbl-1i rroesznca
o Tourism ....... 0 Business ....... 0 Visiting family or friends .... o Cultural ... o Sports ......
TYP1I3M ,[IeJIOBa51 IIOCelI1eHlIe pOI1CTBeHHlIKoB lIJIlIl1PY3en KYJIbTYpa Cnopr
o Official visit o Medical reasons
OCPlIl1lIaJIbHa51 Jlenenae
o Study ..... 0 Transit o Airport transit ...... o Other (please specify)
Yqe6a TpaH31IT TpaH31IT q. aoponopr IIHa51 (YKa3aTb)
~2. Member State(s) of destination 23. Member State of first entry
Crpanau.t) Ha3HaqeHlI51 Crpana nepnoro Bbe311a
~4. Number of entries requested 25. Duration of the intended stay or transit
B1I3a 3arrpaIIIlIBaeTC5II1JIl1 IIP0l10JDKlITeJIbHOCTb rrpe6bIBaH1I5l1IJIli rpaH31ITa
o Single entry .... o Two entries .... 0 Multiple entries
OI1HOKpaTHoro ,[IBYKpaTHoro Mnoroxparaoro Indicate number of days
Bbe311a Bbe311a Bbe311a YKa3aTb KOJIlIqeCTBO I1Hen
.. * The fields marked with * shall not be filled m by family members ofEU, EEA or CH citlzens (spouse, child or dependent ascendant) while exercising their right to free movement. Family members ofEU, EEA or CH citizens shall present documents to prove this relationship and fill in fields no 34 and 35.

IIoJI5I, OTMeqeHHbIe 3HaKOM «*», He 3arrOJIH5IlOTC5I qJIeHaMli cexn.a rpaacian Eaponeiicxoro C0103a, Eaponeitcxoro 3KOHOMlIqeCKOrO Ilpocrpancrna lIJIli Illneituapna (cyrrpyr/-a, l1eTliliJIli 3KOHOMlIQeCKli sanncmrsre pOI1CTBeHHlIKlI rro BOCX0I151lI1en JIlIHlIlI), rrpn oCYlI1eCTBJIeHlIli csoero npana na CB060l1HOe nepezmaaceaae, 110JDKHbI npeztocranars 110KYMeHTbI, nozrraepaciarontae POI1CTBO, 1I 3arrOJIH5IlOT rrOJI5I 34 1I 35.

(x) Fields 1-3 shall be filled in in accordance with the data in the travel document.

IIoJIll 1-3 3arrOJIH5IlOTC5I B COOTBeTCTBlili C l1aHHbIMli

Schengen visas issued during the past three years Illenr encxae B1I3bI, BbIl1aHHbIe sa rrOCJIel1HlIe rpli rona

No 0 Yes. Date(s) of validity from to

ReT ,[Ia. CpOK l1enCTBlI51 C 110

,[IenCTBlITeJIbHO C

110

.Fingerprints collected previously for the purpose of applying for a Schengen visa

OTrreQaTKlI rram.nen, rrpel10CTaBJIeHHbIe panee npn nonane 3a5lBKlI na rronynenae menrencxoti B1I3bI

No 0 Yes. Date, if known

,[Ia ,[laTa, ecrm 1I3BeCTHa

for the final country of destination, where applicable [Paapeurenne na Bbe311 B crpany KOHeQHOrO CJIeI10BaH1I5l, ecnn He06xol1lIMO

by Valid from until

Intended date of arrival in the Schengen area Ilpezmo.naraexraa nara Bbe311a B IIIeHreHcKYlO 30HY

Intended date of departure from the Schengen area Ilpezmo.naraexraa nara BbIe311a 1I3 menrencxoii 30HbI

"UBlanu, and first name of the inviting person(s) in the Member State(s). Ifnot IfP>nnOnr",r"accommodation(s) in the Member State(s)

<DaMliJIlIW-lI, lIM5I (liMeHa) JIlIl1a, nparnanraromero B rocyaapcraor-a Illenrencxor o - nasaaaae rOCTlIHlIl1bI (rocramnt) arm azipec I-a apexremroro npern.mauaa na

address of inviting person(s)/hotel(s)/temporary

1I azipec anercrponaoti rrOQTbI nparnanraromero JIlIl1a (JIlIl1) I IrooCTHHlIl1bI (rocrnnnn) I MeCTa (MeCT) apexremroro nperiunauaa

32. Name and address of inviting company/organisation Hasnanae II azipec nparnamarometi KOMrraHIIII / opraHII3al1IIII

and telefax of company/organisation II cpaKc KOMrraHIIII / opraHII3al1IIII

first name, address, telephone, telefax, and e-mail address of contact person in company/organisation 1"""""'"""', IIM5I, azipec, re.redion, cpaKc II azipec anercrponaoti no-m.r KOHTaKTHoro JIlIl1a KOMrraHIIII / opraHII3al1IIII

33. Cost of travelling and living during the applicant's stay is covered PaCXOl1bI 3a5lBIITeAA na rrpoeszt II BO BpeM5I rrpe6bIBaHII51 OrrJIaqIIBaeT

by the applicant himself/herself

HaJIIIqHble zrem.rn

Accommodation provided

06eCrreqIIBaeTC5I MeCTO rrpmKIIBaHII51

All expenses covered during the stay OrrJIaQIIBalOTC5I see paCXOl1bI BO BpeM5I rrpe6bIBaHII51 Pre-paid transport

OrrJIaQIIBaeTC5I rpaHcrropT

Other (please specify)

Hnue (YKa3aTb)

HaJIIIQHble zrem.rn

Traveller's cheques

,[(opmKHble QeKII

Credit card

KpeI1IITHa51 KapTOQKa

Pre-paid accommodation Ilpenonnaneno MeCTO rrpmKIIBaHII51 Pre-paid transport

IIpel10rrJIaQeH rpaHcrropT

Other (please specify)

Hnue (YKa3aTb)

Personal data of the family member who is an EU, EEA or CH citizen

JIIIQHble zranm.re QJIeHa cem.n, 51BAAlOlI1erOC5I rpazctaaanoxr Enponeiicxoro C0103a, Eaporreiicxor o 3KOHOMIIQeCKOrO Ilpocrpaacrna IIJIII Illnenuapna

name(s) (IIMeHa)

Family relationship with an EU, EEA or CH citizen

POI1CTBO C rpaaciananoxr Eaporreiicxor o C0103a, Eaponeitcxoro 3KOHOMIIQeCKOrO Ilpocrpaacrna IIJIII Illneiiuapnn

spouse 0 child 0 grandchild 0 dependent ascendant

Cyrrpyr/-a Pe6eHoK BHyKl-QKa 1I)!{,[(IIBeHel1

Place and date Mecro IIl1aTa

. Signature (for minors, signature of guardian) IIOl1rrIIcb(I1JI5IHe'COIle~lrn'~HIIOJle rrOJIHOMOQII5lMII

PLEASE

ORDER FULL ~ VERSION i.~ .~

of and consent to the following: the collection of the data reqnired by this application form and the taking of my photograph and, if lapplicahle.fhe taking of fingerprints, are mandatory for the examination of the visa application; and any personal data concerning me which appear on visa application form, as well as my fingerprints and my photograph will be supplied to the relevant authorities of the Member States and processed those authorities, for the purposes of a decision on my visa application.

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 Visa Information System (VIS)2 for a maximum period of five years, during which it will be accessible to the visa authorities and authortties competent for carrying out checks on visas at external borders and within the Member States, immigration and asylum authorities in the 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 of identifying persons who do not or who no longer fulfil these conditions, of examining an asylum application and of determining responsibility such examination. Under certain conditions the data will be also available to designated authorities of the Member States and to Europol for the

of the prevention, detection and investigation of terrorist offences and of other serious criminal offences. The authority of the Member State

lresponsfble for processing the data is: [( ... )].

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 which transmitted the data, and to request that data relating to me which are inaccurate be corrected and that data relating to me processed 11I~II"wfll"V 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 data concerning me and have them corrected or deleted, including the related remedies according to the national law of the State Iconcel"lnelri. The national supervisory authority of that Member State [contact details] will hear claims concerning the protection of personal data.

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 lap'pliication 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 deals with the application.

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 ouly one the prereqnisites 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 be entitled to compensation ifI fail to comply with the relevant provisions of Article 5(1) of Regulation (EC) No 562/2006 (Schengen Borders Code)

I am therefore refused entry. The prereqnisites for entry will be checked again on entry into the European territory of the Member States. llHCPOpMllpoBaH/-a II cornaceu=ua C TeM, qTO npeztocrannenne MHOIO MOliX JIllqHbIX l1aHHbIX, nocrpcfionanm.tx B nacroamcii amcere, cpoTorpacplipoBaHlie ll, B He06xol111MOCTll, CH5ITlie OTrreqaTKOB nam.uea 51BMeTC5I 06513aTeJIbHbIM I1JI5I paccuorpenaa 3a5laBJIeHll51 na B1l3Y; see JIllqHble ztamn.re, OTHOC5III111eC5I KO npeztocrannemn.re B B1l30BOll amcere, 6Yl1YT nepenansr KOMrreTeHTHbIM opranaxr rocvaapcrn-yaacmmcoa Illenrencxoro cornamenaa II 6Yl1YT llMli [oopanoram.r I1JI5I npanaraa pemenaa rro MoeMY 3a5lBJIeHllIO.

ztamn.re, KaK a ztamn.re 0 pemenaa, rrpllH5ITOM rro MoeMY 3a5lBJIeHllIO, llJIli 0 pemennn aHHYJIlipOBaTb, OTMeHllTb llJIli nponrnrrs yace BbIl1aHHYIO B1l3y, 6Yl1YT II coxpanensr B B1l30BOllllHcpopMal1110HHOll cncrexre (VIS)2 na MaKCliMaJIbHbIll CpOK nsm, JIeT II B 3TOT nepnozt 6Yl1YT 110cTyrrHbI rocYl1apCTBeHHbIM ly~[pE:)i(i~el~1l5lM II cny)!(6aM, B KOMrreTeHI111IO KOTOPbIX BX0I111T rrp01l3B0I111Tb rrpoaepxy B1l3 na nnenmax rpananax menrencxoa aom.r II B ee crpaaax-ynacrnaxax, llMMlirpal1110HHbIM CJIy)!(6aM II yqpe)!(!1eH1l5lM rrpeI10CTaBMIOII111M y6e)!(1lIl1e, C l1eJIbIO YI10CTOBepllTbc5I, C06JIIOl1aIOTC5I JIll rperionauau rro 3aKoHHoMY npetn.manaro II rrpcororaanaro na 'reppnropaa crpan-ynacrnaxoa, a TaK)!(e I1JI5I orrosnanaa mm, xoropsre He COOTBeTCTBYIOT arm CTaJIli He ICO'O'I"BeTC'TB'OB,aTb 3TllM rpe60BaH1l5lM, 11M paccxrorpenaa npomenati 0 npeztocrannenaa y6e)!(1lll1a II onpezterrenaa OTBeTCTBeHHOCTli sa rr0l106HOe paccxrorpenne. nexoropsrx YCJIOB1l5lX zranm.re 6Yl1YT 110cTYrrHbI TaK)!(e orrpeaeneam.rxr cny)!(6aM rocvnapcra-ynacrnaxoa II Eaponorry I1JI5I npeztorapamenna, pacxpsrras II Ipa.cCJIe.110BaHIlI51 npaaonapymenati, CB5I3aHHblX C 'reppopasxroxr, a ztpyrnx T5I)!(KliX npecryrr.tenna. [ocYl1apCTBeHHbIM vnpezctenaeu, OTBeTCTBeHHbIM sa 10bpat)0'I"KY l1aHHbIX, 51BJI5IeTC5I [( ... )].

113BecTHo, qTO B JII060M rocvztapcme-ynacrnaxe 51 llMeIO npano no.tymrrs YBel10MJIeHlle 0 l1aHHbIX, KaCaIOII111XC5I MeH5I II BBel1eHHbIX B (VIS), II 0 rrpeztocrananurexr TaKlie ztamn.re, a TaK)!(e rpetionan, acnpannenaa neaepm.rx l1aHHbIX, KaCaIOII111XC5I MeH5I, II Yl1aJIeHll51 MOliX JIllqHbIX

06pa60TaHHblx rrporanosaxonno. ITo MoeMY OC060MY sanpocv yqpe)!(!1eHlle, orpopunmomee Moe sasmnetrne, C00611111T MHe 0 cnocofie oCYll1eCTBJIeHll51 na rrpoaepxy JIllqHbIX l1aHHbIX 060 MHe, a TaK)!(e na acnpaanenne arm yaanenne l1aHHbIX B nopaznce, YCTaHOBJIeHHOM Hal1110HaJIbHbIM 13aKOHO'l1aTeJIbCTBOM COOTBeTCTBYIOlI1erO rocyziapcraa. OTBeTCTBeHHoe na Hal130P yqpe)!(!1eHlle COOTBeTCTBYIOlI1erO rocyztapcrna-vnacraaxa [contact details] Ipa.ccMC)TJ:mT )!(aJI06bI rro 3all111Te JIllqHbIX l1aHHbIX.

3aBep5lIO, qTO see ztamn.re, 1106pOCOBecTHo vxasamrsre MHOIO B amcere, 51BMIOTC5I npanam.asnra II rrOJIHbIMli. MHe 113BeCTHO, qTO JIO)!(Hble zranm.re xroryr

Tb rrpllqllHOll OTKa3a llJIli aHHYJIlipOBaHll51 yace BbIl1aHHOll B1l3bI, a TaK)!(e non.rem, sa C060ll yrOJIOBHOe npec.reztonanae B COOTBeTCTBlili C 3aKOH0l1aTeJIbCTBOM rocynapcraa-yuacrnaxa Illenrencxoro cornarrretras, xoropoe OcpopMJI5IeT MOIO B1l30BYIO aHKeTY.

B1l3a 6Yl1eT BbIl1aHa, 51 06513YIOCb rroxaayrs 'reppnropmo rOCYl1apCTB-yqaCTHliKOB Illenrencxor o cor

llHCPOpMllpoBaH/-a 0 TOM, qTO nann-rae B1l3bI 51BMeTC5I nann, OI1HllM 113 YCJIOBllll, He06xol111MbIX 11M ly~[aCTHll~:OB Illenrencxor o cornanrenaa. CaM cpaKT rrpel10CTaBJIeHll51 B1l3bI He l1aeT npana na rronynenae

ITPeOI)B<IHIIll nyrncra 1 crart.n 5 Pernaxrenra (EK) N2562/2006 (Illenrencxoro KOl1eKCa 0 rpammax), na enponeitcxyro 'reppnropmo rocyaapcm-yuacrnaxoa Illenrencxor o cornaurenax

ORDER FULL

VERSION

2

Insofar as the VIS is operational/Ecnn VIS paooraer.

~o VER8~

Q«; O~

PLEASE

ORDER FULL \ VERSION E

~ CJO

.~ ~.