Word版申根签证申请表

ApplicationforSchengenVisaThisapplicationformisfreePHOTO1.Surname(Familyname)(x)FOROFFICIALUSEONLYZhang2.Surnameatbirth(Formerfamilyname(s))(x)Dateofapplication:Visaapplicationnumber:3.Firstname(s)(Givenname(s))(x)SanApplicationlodgedat□Embassy/consulate□CAC4.Dateofbirth(day-month-year)01JAN20005.PlaceofbirthBEIJING6.CountryofbirthCHINA7.CurrentnationalityCHINANationalityatbirth,ifdifferent:□Serviceprovider□Commercialintermediary□BorderName:8.Sex■Male□Female9.Maritalstatus■Single□Married□Separated□Divorced□Widow(er)□Other(pleasespecify)□OtherFilehandledby:Supportingdocuments:10.Inthecaseofminors:Surname,firstname,address(ifdifferentfromapplicant's)and□Traveldocumentnationalityofparentalauthority/legalguardian11.Nationalidentitynumber,whereapplicable11010820000101222212.Typeoftraveldocument■Ordinarypassport□Diplomaticpassport□Servicepassport□Officialpassport□Specialpassport□Othertraveldocument(pleasespecify)□Meansofsubsistence□Invitation□Meansoftransport□TMI□Other:Visadecision:□Refused□Issued:□A□C13.NumberoftraveldocumentG1234567814.Dateofissue15.Validuntil16.Issuedby□LTV□Valid:FromUntil17.Applicant'shomeaddressande-mailaddressTelephonenumber(s)RoomXXX,No.XXX,XXXRoadHaidianDistrict,Beijing,[e-mail]:□1□2□MultipleNumberofdays:18.Residenceinacountryotherthanthecountryofcurrentnationality■No□Yes.ResidencepermitorequivalentNoValiduntil*19.CurrentoccupationFarmer31DEC2021Exit&EntryAdministrationMinistryofPublicSecurity1380013800001JAN2012*20.Employerandemployer'saddressandtelephonenumber.Forstudents,nameandaddressofeducationalestablishment.BeijingXXXXCo.,Ltd.RoomXXX,No.XXX,XXXRoad,HaidianDistrict,Beijing,China010-8888888821.Mainpurpose(s)ofthejourney:■Tourism□Business□Visitingfamilyorfriends□Cultural□Sports□Officialvisit□Medicalreasons□Study□Transit□Airporttransit□Other(pleasespecify)22.MemberState(s)ofdestinationBelgium,France23.MemberStateoffirstentryBelgium24.Numberofentriesrequested■Singleentry□Twoentries□Multipleentries25.DurationoftheintendedstayortransitIndicatenumberofdays15Days*Thefieldsmarkedwith*shallnotbefilledinbyfamilymembersofEU,EEAorCHcitizens(spouse,childordependentascendant)whileexercisingtheirrighttofreemovement.FamilymembersofEU,EEAorCHcitizensshallpresentdocumentstoprovethisrelationshipandfillinfieldsno34and35.(x)Fields1-3shallbefilledininaccordancewiththedatainthetraveldocument.26.Schengenvisasissuedduringthepastthreeyears■No□Yes.Date(s)ofvalidityfromto27.FingerprintscollectedpreviouslyforthepurposeofapplyingforaSchengenvisa■No□Yes.Date,ifknown28.Entrypermitforthefinalcountryofdestination,whereapplicableIssuedbyValidfromuntil29.IntendeddateofarrivalintheSchengenarea01JUN201330.IntendeddateofdeparturefromtheSchengenarea15JUN2013*31.Surnameandfirstnameoftheinvitingperson(s)intheMemberState(s).Ifnotapplicable,nameofhotel(s)ortemporaryaccommodation(s)intheMemberState(s)XXXHotelAddressande-mailaddressofinvitingperson(s)/hotel(s)/temporaryaccommodation(s)No.XX,XXXRoad,Brussels,[e-mail]l:+32xxxxxxxxFax:+32xxxxxxxx*32.Nameandaddressofinvitingcompany/organizationTelephoneandtelefaxofcompany/organizationSurname,firstname,address,telephone,telefax,ande-mailaddressofcontactpersonincompany/organization*33.Costoftravellingandlivingduringtheapplicant'sstayiscovered■bytheapplicanthimself/herselfMeansofsupport■Cash□Traveller'scheques■Creditcard□Pre-paidaccommodation□Pre-paidtransport□Other(pleasespecify)□byasponsor(host,company,organisation),pleasespecify□referredtoinfield31or32□other(pleasespecify)Meansofsupport□Cash□Accommodationprovided□Allexpensescoveredduringthestay□Pre-paidtransport□Other(pleasespecify)34.PersonaldataofthefamilymemberwhoisanEU,EEAorCHcitizenSurnameFirstname(s)DateofbirthNationalityNumberoftraveldocumentorIDcard35.FamilyrelationshipwithanEU,EEAorCHcitizen□spouse□child□grandchild□dependentascendant36.PlaceanddateBeijing01APR201337.Signature(forminors,signatureofparentalauthority/legalguardian)Iamawarethatthevisafeeisnotrefundedifthevisaisrefused.Applicableincaseamultiple-entryvisaisappliedfor(cf.fieldno24):IamawareoftheneedtohaveanadequatetravelmedicalinsuranceformyfirststayandanysubsequentvisitstotheterritoryofMemberStates.Iamawareofandconsenttothefollowing:thecollectionofthedatarequiredbythisapplicationformandthetakingofmyphotographand,ifapplicable,thetakingoffingerprints,aremandatoryfortheexaminationofthevisaapplication;andanypersonaldataconcerningmewhichappearonthevisaapplicationform,aswellasmyfingerprintsandmyphotographwillbesuppliedtotherelevantauthoritiesoftheMemberStatesandprocessedbythoseauthorities,forthepurposesofadecisiononmyvisaapplication.Suchdataaswellasdataconcerningthedecisiontakenonmyapplicationoradecisionwhethertoannul,revokeorextendavisaissuedwillbeenteredinto,andstoredintheVisaInformationSystem(VIS)1foramaximumperiodoffiveyears,duringwhichitwillbeaccessibletothevisaauthoritiesandtheauthoritiescompetentforcarryingoutchecksonvisasatexternalbordersandwithintheMemberStates,immigrationandasylumauthoritiesintheM