Embassy of Italy

Doha

Harmonized application form. FOTOGRAFIA

Application for Schengen Visa.
This application form is free

1.

Family members of EU, EEA or CH citizens or of UK nationals who are beneficiaries of the EU-UK Withdrawal Agreement
shall not fill in fields No 21, 22, 31, 32 and 33 (marked with*).

Fields 1–3 shall be filled in in accordance with the data in the travel document.

1. Surname (Family name): HOSSAIN For official use only

Date of application:
Application number:
2. Surname at birth (Former family name(s)):

3. First name(s) (Given name(s)): MAMUN

4. Date of birth (day- 5. Place of birth: CHANDPUR 7. Current nation- Application lodged at:
month-year): ality: ☐ Embassy/Consul
01-01-1978 BANGLADESHI - late
Nationality at birth, if
different: ☐ Service provider
6. Country of birth: BANGLADESH
Other nationalities:
☐ Commercial in-
term diary

8. Sex: 9. Civil status: ☐ Border (Name):

☐ *Male ☐ Single ☐ *Married ☐ Registered Partnership ☐ Separated ☐ Divorced ☐ ..................
☐ Female Widow(er) ☐ Other (please specify):
☐ Other ☐ Other:

10. Parental authority (in case of minors)/legal guardian (surname, first name, address, if File handled by:
different from applicant’s, telephone No, email address, and nationality):

11. National identity number, where applicable: 9579180952 Supporting

documents:
☐ *Travel document
☐ Means of subsis-
tence
☐ *Invitation

1. No logo is required for Norway, Iceland, Liechtenstein and Switzerland.

12. Type of travel document:
☐ *Ordinary passport ☐ Diplomatic passport ☐ Service passport ☐ Official passport ☐ Special ☐ TMI
passport ☐ Means of trans-
☐ Other travel document (please specify): port
☐ Other:

13. Number of travel 14. Date of issue: 15. Valid until: 16. Issued by
document: 30-08-2023 29-08-2033 (country):
A11990181 BANGLADESH Visa decision:
☐ Refused
☐ Issued:
17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who ☐ A
is a beneficiary of the EU-UK Withdrawal Agreement, if applicable ☐ C
☐ LTV

Surname (Family name): First name(s) (Given name(s)): ☐ Valid:

From:
Date of birth (day- Nationality: Number of travel
month-year): document or ID card:
Until:

18. Family relationship with an EU, EEA or CH citizen or a UK national who is a beneficiary of
the EU-UK Withdrawal Agreement, if applicable:
☐ spouse ☐ child ☐ grandchild ☐ dependent ascendant
☐ registered partnership ☐ other:

19. Applicant’s home address and email address: STREET-22, ZONE-40, Telephone no.:
VILLA-13, NEW SALATA, DOHA, QATAR +97433666125

20. Residence in a country other than the country of current nationality:

☐ No
☐ *Yes. Residence permit or equivalent: No. 27805000466 Valid until:09-08-2024

21. * Current occupation: BUSINESSMAN Number of entries:

☐ 1 ☐ 2 ☐ Multiple

22. * Employer and employer’s address and telephone number. For students, name and address
of educational establishment:
Number of days:

23. Purpose(s) of the journey:

☐ *Tourism ☐ Business ☐ Visiting family or friends Cultural ☐ Sports ☐ Official visit ☐ Medical
reasons Study ☐ Airport transit ☐ Other (please specify):

24. Additional information on purpose of stay:

25. Member State of main destination (and 26. Member State of first entry: ITALY
other Member States of destination, if ap-
placeable):

27. Number of entries requested:

☐ Single entry ☐ Two entries ☐* Multiple entries
 28. Intended date of arrival of the first intended stay in the Schengen area:
Intended date of departure from the Schengen area after the first intended stay:

29. Fingerprints collected previously for the purpose of applying for a Schengen visa:
☐ No ☐Yes.
Date, if known . . . . . . . . . . . . . . . . . . . . . . . .. Number of the visa, if known . . . . . . . . . . . . . . . . . . . . . . . .. .

30. Entry permit for the final country of destination, where applicable:

Issued by . . . . . . . . . . . . . . . . . . . . . . . . Valid from . . . . . . . . . . . . . . . . . . . . .. until . . . . . . . . . . . . . . . . . . . . .. .

31. *Surname and first name of the inviting person(s) in the Member State(s). If not applicable,
name of hotel(s) or temporary accommodation(s) in the Member State(s):

Address and email address of inviting person(s)/ Telephone No:

hotel(s)/temporary accommodation(s):
TOBIA LUGI EMANUELE

32. *Name and address of inviting company/organization:

DREPANUM MARBLE S.R.L.S, BORBONI N .35 C.A.P.91100

Surname, first name, address, telephone No, and Telephone No of company/organization:

email address of contact person in company/ +393286748192
organization: TOBIA LUIGI EMANUELE

33. *Cost of travelling and living during the applicant’s stay is covered:

☐ by the applicant ☐ by a sponsor (host, company, organisa-

Means of support: tion), please specify:
☐ *Cash
☐ referred to in field 30 or 31
☐ Traveler’s cheques
☐ *Credit card ☐ other (please specify):
☐ Pre-paid accommodation Means of support:
☐ Pre-paid transport ☐ Cash
☐ Other (please specify): ☐ Accommodation provided
☐ All expenses covered during the stay
☐ Pre-paid transport
☐ Other (please specify):

34. Surname and first name of the person filling in the application form, if different from
the applicant:

Address and email address of the person filling in Telephone No:

the application form:

1. No logo is required for Norway, Iceland, Liechtenstein and Switzerland.

 I am aware that the visa fee is not refunded if the visa is refused.

Applicable in case a multiple-entry visa is issued:

I am aware of the need to have adequate travel medical insurance for my first stay and any subsequent visits to the territory
of 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 application; and
any personal data concerning me which appear on the 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 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 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 the Member State responsible for processing
the data is: [( .............................................................................................................................................................. )].
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 Member State
concerned. The national supervisory authority of that Member State [contact details:] 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 6(1) of Regulation (EU) 2016/399 (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.

applicable):’.