Embassy of Italy

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Application for Schengen Visa
THIS APPLICATION IS FREE

1.Surname (Family Name)

For office use only:

2.Sumame at Birth (previous surnames) Date of application:

3.First Name(s) (Given name(s)) Visa application number

Application lodged at
4. Date of Birth 5. Place of Birth 7. Current NationalityINationality at Birth,
(DaylMonthNear) if different Embassy/Consulate
CAC
6. Country of Birth
Service provider
8. Sex 9. Marital Status Commercial intermediary

Male C] Female Single Married Separated Divorced [7 Widow(er) Border

[7 Other (please specify)
, Name
10. In the case of minors : Sumame, First Name, Address (if different from applicant's) and'nationality of other
parental authorityAegal guardian
File handled by:

11. National Identity number, where applicable

Supporting documents:
C] Travel document
Means of subsistence
12. Type of travel document C] Invitation
C] Ordinary Passport C] Diplomatic Passport C] Service Passport official Passport Special Passport Means of transport
Other travel document (please specify) [7 TMI
[7 Other
13. Number of travel 14. Date of issue 15. Valid until 16. Issued by
document
Visa decision
\ [7 Refused
17. Applica s home address and e-mail address Issued
'It:. Telephone Number(s)
\
A
c
18. Residence in a country other than the country of current nationality
LW
No
Yes, Residence permit or equivalent .......................... No ..........................Valid until
Valid
*I
9. Current occupation From ......................
Until .......................

Number of entries:
*20. Employer and employer's address and telephone number, For students, [7 1 0 2 Multiple
name and address of educational establishment
, Number of days:
 21. Main purpose(s) of the journey.
Tourism Business Visiting family or friends Cultural Sports
Official visit
Medical reasons
Study Transit Airport transit 17 Other (Please specify)

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

1 22. Member State@)of destination 1 23. Member State of first entry

24. Number of entries requested 25. Duration of the intended stay or transit
Single entry Two entries Indicate number of days

Multiple entries 17

26. Schengen visas issued during the past three years.

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

27. Fingerprints collected previously for the purpose of applying for a Schengen visa
NO Yes
..........................................................................................................
Date. if known

28. Entry permit for the country of destination, where applicable

lssued by ..............................Valid from ...............................until....................................

29. Intended date of arrival in the 30. Intended date of departure

Schengen area from the Schengen area
-i

I
*31. Surname and first name of the inviting person(s) in the Member State@).
if not applicable: name of hotel@)or temporary accomodation(s) in the hember State(s)
i .
1
\
Address and e-mail address of inviting person(s)/ hotel@)I Telephone and fax
temporary accommodation(s)

*32. Name and address of inviting company / organization Telephone and fax of
company / organization
I
Surname, first name, address, telephone, fax and e-mail address of contact person I company /
organization
 33. Cost of traveling and living during the applicant's stay is covered

by the applicant himselflherself by a sponsor (host, company, organization), please

Means of support specify

.............................. referred to in field 31 or 32

Cash
0 Other (please specify)
Traveller's cheques
Means of support
Credit card
Cash
Prepaid accommodation
Accommodation provided
Prepaid transport
All expenses covered during the stay
Other (please specify)
Prepaid transport

Other(please specify)

The fields marked with *shall not be filled in by family members o f EU, EEA or CH citizens (spouse, child or dependent
.
ascendant) while exercising their right t o free movement. Family members o f EU, EEA or CH citizens shall present
documents t o prove this relationship and fill in fields N o 34 and 35.

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

Surname First name(s)

Date of Birth Nationality Number of Travel document

or ID card

I I
35. Family relationship with an EU, EEA or CH citizen
spouse 0' child ............................................ grandchild dependent ascendant

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36. Place and date 37. Signature

(for minors, signature of parental

I authorityllegal guardian)

I am aware that the visa fee will not be refunded if the visa is refused:
,
 Applicable in case a multiple - entry visa applied for (cf. field No 24):

I am aware of the need to have an adequate travel medical insurance for my first stay and any subsequent visits to the territory of
I
Member States.

- - -

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
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 fulfill 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 the Member State is responsible for processing the data.

I am aware that I have right to obtain in any of the Member States notification of the data to me recorded in the VIS and of the
Member States 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 will hear claims concerning the protection of personal data. I

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 yith 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.

Place and date Signature (for minors, signature of parental authorityllegal guardian):