System Zdalnej Rejestracji 6z2b6z

System Zdalnej Rejestracji

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https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...

and conditions

e-Konsulat Home page > New Delhi > Visa > National Visa - Fill in form > Registration of visa application

This template will allow for the filling out and printing of your visa application only. To make an appointment in a selected Consular office, you are required to your visa application.

Visa National Visa form National Visa Schengen Visa form Schengen Visa

Application for national visa

Fill in form - - Fill in form

Fields No: 1, 2, 3, 5, 11, 13, 16, 31, 34 should be filled in by using the Latin alphabet letters only (A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z). Any erroneous entry shall make the application void.

Personal data 1. Surname (s) (family name(s))

Visits Legal matters Cancel appointment

2. Surname (s) at birth (previously used surname (s))

3. First name(s)

4. Date of birth (year-month-day)

5. Place of birth

6. Country of birth 7. Current nationality/ies Original nationality (nationality at birth) 8. Sex

9. Martial status

Male

Single

Female

Married Separated Divorced Widow(er) Other

National identity number

port data 12. Type of travel document Ordinary port Diplomatic port Service port Official port Special port Other travel document (please specify):

13. Number of travel document

14. Date of issue (year-month-day)

15. Valid until (year-month-day)

16. Issued by

10.In the case of minors: Surname, first name, address (if different from applicant’s) and nationality of parental authority/legal guardian does not apply Nationality First name Surname Country State/province Place Postal code

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System Zdalnej Rejestracji

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https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...

Address

17. Applicant’s home address and e-mail address Country State/province Place Postal code Address Current email Email address. Other e-mail addresses than the one provided in the VISA Application Form shall not be used when ing an applicant. Phone area code Phone number 18. Residence in a country other than the country of current nationality No Yes. Residence permit or equivalent Number Expiry date

indefinitely

* 19. Current occupation

* 20. Employer and employer’s address and phone number. For students, name and address of school Employer School State State/province Place Postal code Address Phone area code Phone Name Email Fax area code Number of fax 21. Main purpose(s) of the journey: Tourism Business Visit to family or friends Cultural Sports Official visit Medical reason Study Other (please specify):

Details regarding travel arrangements. 22. Destination country

23. Member State of first entry

24. Number of entries requested

25. Duration of stay:

Single entry

Visa requested for

days (>90)

Two entries Multiple entries 29. Intended date of arrival to the Republic of

30. Intended date of departure from the Republic of

Poland (year-month-day)

Poland (year-month-day)

The fields marked with * shall not be filled in by family of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to free movement. Family of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields No 34 and 35. 26. National visas issued during the past five years No Yes. Date(s) of validity

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System Zdalnej Rejestracji

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https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...

from (year-month-day):

to (year-month-day):

27. Fingerprints collected previously for the purpose of applying for a Schengen visa No Yes

28. Entry permit for the final country of destination, where applicable does not apply

Data of receiving person * 31, 32. Surname and first name of the inviting person(s) in the the Republic of Poland. If not applicable, name of hotel(s) or temporary accommodation(s) in the the Republic of Poland.

Type

Person Company

Name First name Surname Country Place Postal code Phone area code Phone number Fax area code Number of fax Address House number Flat number E-mail address

Data of person covering expenses * 33. Cost of travelling and living during the applicant’s stay is covered by the applicant himself/herself By a sponsor (host, company, organisation), please specify referred to in field 31 or 32 other (please specify)

Means of during your stay Cash Travellers cheques Credit cards Accommodation Prepaid transport All expenses covered during the stay Other: Travel and/or health insurance. Valid until:

EU citizen data 34. Personal data of the EU or EEA citizen you depend on. This question should be answered only by family of EU or EEA citizens. does not apply Surname

First name

Date of birth

Number of port

Nationality spouse Relationship:

child grandchild dependent ascendant

Applicant's data I am aware that the visa fee is not refunded if the visa is refused. Applicable in case a multiple-entry visa is 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 Member States. I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that the submission of an application and/or supplementary documents containing untrue personal data or false information, declaration of untruth or the suppression of truth, forgery or tampering with a document with the intent of ing it off as genuine or the use of such a document as genuine will lead to my application being rejected or to the annulment of a national visa already granted, and may also render me liable to prosecution under Polish law. I undertake to leave the territory of the Republic of Poland not later than the last day of the national visa’s validity. I am aware that possession of a visa is only one of the prerequisites for entry into the territory of the Republic of Poland. The 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 the Law on Aliens and am refused entry. The prerequisites for entry will be

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System Zdalnej Rejestracji

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https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...

checked again on entry into the territory of the Republic of Poland. I am aware that a granted national visa may be revoked if I no longer meet the requirement for its issuance.

* Questions marked with * may be omitted by family of EU or EEA citizens (spouse, child, or dependent ascendant). Family of EU or EEA citizens have to present documents proving this relationship. Please make sure that the data entered in the Visa Application Form are correct and press SAVE button to confirm it. Press CORRECT button if you need to amend any data you have entered in the Application Form. Any erroneous entry shall make the application void. Continue

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(c) Ministerstwo Spraw Zagranicznych | and conditions |

21-Nov-17 6:16 PM