Application for Schengen Visa

This application form is free

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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, 30, 31 and 32 (marked with*).
Fields 1-3 shall be filled in in accordance with the data in the travel document.

1. Surname (Family name): WYŁĄCZNIE DO

UŻYTKU URZĘDOWEGO
Data złożenia wniosku:
2. Surname at birth (Former family name(s)):
Numer wniosku:
3. First name(s) (Given name(s)):
Wniosek złożono:
□ w ambasadzie/konsulacie
4. Date of birth 5. Place of birth: 7. Current nationality: □ u usługodawcy
□ u pośredniczącego
(day-month-year):
podmiotu komercyjnego
Nationality at birth, if different: □ na granicy (nazwa):
6. Country of birth: ………………………….
………………………….
Other nationalities: □ inne:
8. Sex: 9. Civil status:
□ Single □ Married □ Registered Partnership □ Separated
□ Male □ Female □ Divorced □ Widow(er) Wniosek przyjęty przez:
□ Other □ Other (please specify):
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different from
applicant’s, telephone No., e-mail address, and nationality): Dokumenty uzupełniające:
□ dokument podróży
□ środki utrzymania
11. National identity number, where applicable: □ zaproszenie
12. Type of travel document: □ podróżne ubezpieczenie
medyczne
□ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport
□ środek transportu
□ Special passport □ Other travel document (please specify): □ inne:
13. Number of travel 14. Date of issue: 15. Valid until: 16. Issued by (country):
document:

17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who is a beneficiary Decyzja o wizie:
of the EU-UK Withdrawal Agreement, if applicable: □ odmowa
□ przyznano wizę:
Surname (Family name): First name(s) (Given name(s)): □A
□C
□ o ograniczonej ważności
Date of birth Nationality: Number of travel document or ID card: terytorialnej
(day-month-year): □ okres ważności:

18. Family relationship with an EU, EEA or CH citizen or a UK national who is a beneficiary of the EU-UK Od:
Withdrawal Agreement, if applicable:
Do:
□ spouse □ child □ grandchild □ dependent ascendant □ registered partnership
□ other: Liczba wjazdów:
19. Applicant's home address and e-mail address: Telephone no.: □ 1 □ 2 □ wielokrotny
Liczba dni:

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

□ No
□ Yes. Residence permit or equivalent ………………… No. ………….…………….
Valid until ……………………….……
*21. Current occupation:
*22. Employer and employer’s address and telephone number. For students, name and address of educational
establishment:

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 other Member States of 26. Member State of first entry:
destination, if applicable):

27 Number of entries requested:

□ Single entry □ Two entries □ Multiple entries

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:

28. Fingerprints collected previously for the purpose of applying for a Schengen visa:
□ No □ Yes.
Date, if known …………………… Visa sticker number, if known …………….……

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

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

*30. 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 e-mail address of inviting Telephone no.:

person(s)/hotel(s)/temporary accommodation(s):

*31. Name and address of inviting company/organisation:

Surname, first name, address, telephone No., and e-mail address of Telephone No. of company/organisation:
contact person in company/organisation:

*32. Cost of travelling and living during the applicant’s stay is covered:
□ by the applicant himself/herself □ by a sponsor (host, company, organisation), please
Means of support: specify:
□ Cash □ referred to in field 30 or 31
□ Traveller’s cheques □ other (please specify):
□ Credit card Means of support:
□ Pre-paid accommodation □ Cash
□ Pre-paid transport □ Accommodation provided
□ Other (please specify): □ All expenses covered during the stay
□ Pre-paid transport
□ Other (please specify):
33. 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 the application Telephone No::
form

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: Centralny Organ Techniczny KSI, Komendant Główny Policji, Puławska
148/150, 02-624 Warszawa.

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: Prezes Urzędu Ochrony Danych Osobowych,
ul. Stawki 2, 00-193 Warszawa] 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.

Place and date: Signature of applicant:

(signature of parental authority/legal guardian, if applicable):