Application for Schengen Visa

This application form is free

1. sumam6(s) (ramily namo{s)) (iln^}er).r , FOR EMSASSY USE ONLY

2. Surname(s)at birth {oarlierlamily name(s)) (irJrlr,jri) -!, & dl

3. Firct nams {siven names) Jrlr +lr
4. Oate of blih (ya.{onrhday) (.J!r-}rir- ,) nrlle} 5. Place and 6. country ol binh ;J)Jr+rJls- Supporiing documents:

T.Cursntnationalily/los llLJr!-i+lr orjginal nationality (narionality at birth) nllr E !-n:lr ! vatt passpon:
E nancialmeans
F-

E lnvitation
f. ilarital stat|,3: i-r.3-)1alJl E Means ol tlanspon
E Mal ,sr tr Fsmato .p! Srngle -rri,[- E Maried ((l<r/ E SeparareO r:* E Hoiel/Accommodation
E Divorced E widow(r) I i)]j E olher r>r -tL- E Heallh insurance
10. Farhds nlne -Jr ..1 10. ilolhs"s n.r| r! r.r E other:
1t. lD-numbor (optional) v!-lr.tjr ,!r3 q+rl
12. Typ6 ofpassporl: iJ jrr. ei E Compl ! lncomp
D Odinary passporl ,JE E Oiplomatic passpon gaurb D Spciatpasspon ,-L _r,- _t+
!] 9q]icep6sp(ri li E olhr iravetdocumni (pteass specit): g..]s--1y c>l_*,!*r
13. Number ol passpod -!..jri>.!) 14. Date ot issue ,rL)rej,
15.V.lid un$l .!-)re,ri 16.lssued by lLlrle
17. Applicanl's home address,]! *r.]i.rsi r,J..lr Tolophone numbor/mobile UJlI,lr ,l
"[il]r

t& ryou Esident ina coontry ottrerttran youi@ EKIS

E No x E "es p 'J, jlrJ,Lri)c.F.irl.l..Jr-),-j:!r),IJr-r,-, E NEG. E POS,
Lli)r .r-)--j .rr !j5 u+_,
Sign.:

' 19- Curront occupation' i,i,Llr q-lr vtsa

E Retussd E cranied
20. Employ6rand employer's addrcss aia tolphone numbar.' For stu(hnts, nam and addre$ ot schoot. Sign.:

.l+lfJarJl.llrll J55u+_, :iJ!!n"^,lq .J-,11"{+u.}i,FJJorr-

2l Pupo$ottrawl !r er]l'
Businsss J- E VotbFanty.F,irrds lj-kJ]! t)!) E CutiuUspons iJl/.--L
L I L'ticEt t+r .+ E lMedcd 166016 a).x E Olh (deassspot). (.rlJ)r>r-/, Characterl6tics ot Vlsal
22. Main destination tr-+-rUJr ie, 23 Aorder o, first eniry or lransil roule ;rir":-jl trAtrctrwL
24. Numbr ot entri.B requested LrJ.-I nrr ru 25. DuEtlon oa stay .L)r r
E Sinsle snry G'j t}. E
rwo entis L!-! E Vua n qudred fo!: dayi Numbr of entrlo3:
26. Othervls.3 (i.suod during lhe pa3t thre years)ana tetr perioO orvatrity i>- u;r-1J.e!<r-/ tr1tr2EIVULT
+U.)- or trFlr irj"" c,x
27. Have your lingerints b@n takn prvlousty for a Schongon visa apptication ut-!tr.d* nr;..Jr 201.
a&;r,l, + JJ-J|!-,ul
E t'to x 5 Yes .! whn J+ .. .. ..
you;n;@
2& lnlh6 calo of lranslt, hde
Ll Nox L-l Yes& vardunu U,l.,r-. rl-J' .:r,r--
J r ,!JF.=IJ- 201...
lssurng auihonty , ;-J' - ,-' .r, ..-r,
' 29. Dale ol arival in Schongen -i+-[ JFrr ejll ' 30. Dale ot departurc tlm Sche.gon ;+Lr tA]i el

'Thequostionsmarkedwilh'donothavtotoanswerodbytamilymembersotEU/EWRciiizns(spouse,chitdord.pendeni
ascendant). Family mombers or EU/EEA/CH citizens have to prosnr documenrs to p.ovethis rotatroirahrp.
ilrLir- trq! Jxr r! xJ" -$J r LL Lrlr)!.irr ix-y !-qr r! (.jL(]i!,(a)aJt)lrrrtr t4L-5) c,+-l r,,Jrr! ,LyL !j! ,* I e rrr r,- .
' 31. Name of host ln the Schengon slates. OiirJl O. sclil Lr-Jl |-r
'32 Name otcompany and contact person ofth cmpany. J-".rrr !r JjlJ !6J' -rj +rilr isr,ijl pr
llnot appli@blo, givo namo of hotlor temporaryaddross in the Schongen steies. pL ,!:l Jll]!t.& {l!;,
Or-irJr JJr vr cl..r-lr oJjJr rt JJil
Namo of hosi / hor6t jilr rrl / gl:rJr rFJl -l E{all adclro3s *-,ttrtr-
",r]jJyr

Namo of company and conlacl p.r3on ot compaoy +lJl .sr.iir.-r Ielophone and iolofax .rllJrr .jJl{lr F, E NEG.
LlLi)] LJa Ji,Jl LJaJt.-1r E POS.

Fulr addross ..1.r5! ur!l

' 33. Who is paying to.yourcosl ollravelling and roryoLrrcosts of living during your stayu lGy 1[] @p9.;. trA
(Slate who and how and p.esenl @rosponding documentation t (lrJuriu JIL q4 L.+n s:2) trc
trD
tr Mysdt U-j.rU tr Cssh +,i, E Ilavllels cnaques !'g-..r$.: File lodged at
E Employr/Company isrldJ i.{+ tr Crdil cards ulnl oull,, tr Other 6!.r't
E tblcompsnyor p.sor/s s.l]lllj'.!ll Jrpu isJr! tr AII c.6ts arc paid by Employer/Company/Hosl E cAc
tr olher ,r>l ,Jry e.lJl o-Jfr. Ur isll ir rJsnl ails
/r3rJl J- i.
E serutce

E TEvel/ heallh imuran 6v.* a'}r.Li r-.}.* tr p.paid accommodalion ue l!ri! Lli)l-rJrs: E commercral
Valad until: :
^r"l ax- ! propaid iranspod li* &Ji! .Jiilr .+lLsi
E Eoder
34.Personal data olthe EU/EEA/CH cittzgn you depnd on. Thts quesiion sibuidEansword oniy
by tamily mombB.of EU/EEA/CH citi:ens JJlI rrJrlt -lj)r J, J+.rJr .J,islr J. r! i* -rja i ott",
+rr!rir.r.-, r i. r-+-r Jr.r v+rrJlr ,t rr Jjl u ,L!r.r .rl u-l !i; JrJr r, -1" i,L+r .a -r.rryr r],L;i1r rr.--i
Dare of Bjdh r)r-ir erLr umber of passport r^Jr rLr+ .iJ

3s. Famiry .olationshlp of EU/EEA/CH citi2ens orJJ\r t .r-rtrt-,"JrJ;l;,Ir r.rtnIJ-;It=qElr{-

tr E chtd rj,)Lu!E glandchitd !!iJ_ r/+JrE
spowa.r,lve r_,lr d6pend6nr ascendant .!- utlJ .L)ii
I amawarethatthevbafeisnotretundedffi

Ardi=Ue in 6e a muliidenby vlsa is apdid ro. (d fdd No 24):

I am awar of lhe need to hav6 an adequale Uavl medical insu.ance for my frst stay and any subGquent visils to ihe ierito.y of [,4embe. Stals.

I am awars of and consert io the iClowingi lt)e colle.tion of th dala Equid by tnis apdication form and ltle raktng of my pMogmph and, if apdicabte, tle
takirE ol fingtprints, are nandalory ior lhe examinalion of lhe visa apdication; and any prsonal dala conceming lhe which appar on lhe visa appticat on
rorm. 6 well as my lingap.ints and my pMograph wilr b supdid lo ihe rclevanl auth..ities of Memb. Sraiss and p.ocessEd by tio6e aulho.nj6, ro. ih
puDc6e ol a decilion @ my visa application.

Such dala 6 wdl as data coftarning lh6 decbion taken on my application d a dedsion whther io annul, revoke d snst a visa issud witl be enied
irio, and stord in th6 vls (in so hr Ul VIS is oPtio.al) ro. a maximum p.ird ol fw ysar, dunrE which it wlr be ac.essjue io the visa auihor,itis and
fte auihodlios compolarlt for carrying out checks on visa al enmal bordrs and within the Member Stal6, immigtion and a$4um auttro.ilis in the
Ivemb. Slales for tre purposs o{ ven6/rng whehe. lh condiliois ior lh6 legal enrry into, si,ay and ,esiden on lh6 renilory ot rhe Mmbr Stats are
tulfiled, of irnt ing p..sorE wtio don nol or wtlo no loiger furi lhse coidilbrE ol ominirc an 6y'um apdkslioi an of det.mining Esponsibiliiy tor
sucn oxaminalion. Under cerlain condiiions tho dala will b also availablo io dsignated authodies of lh l\,!6mber Srates and to Europor for lh purpoGe or
lhe prover'lion, delclion and invesligaiion ot tncrisl offnces ad ol oi\er serious diminal offenc6. lh authodiy ol the lrembr Stal6 Gslonsibre tor

I am aware ihat I have tt'e right lo oblain in any of the lvomber Slates noulicalion ol the data .elating to me Eco.ded in the VIS and ot the lvember Stale
rnich tarEmitled th data, ard io requ6sl thal data rdaling lo rn6 whrh ,e inacafate be conectd ard thal .!ate Elatng to me tr cssed uriawruty be
dlotd. Al my epress roquesl lhe althoriry ermining my applrcalion will infom m6 of ih6 mann6r in trhich I may exercise my ighl lo chec( lhe personat
daia con6ning m and have lhem con.ted or deleted, including the l6ted lemsdies according io lhe nalionar raw of the Sial6 concrrEd. The nalionar
s!p.l/iso.y aJtuily of lhai Memb. state (conLct details) will ha. dsims coi.srnirc lhe plorecriorl o{ pqsd data.

I dclarc lhal io lhe best of my knowldge all pariiculaE suppliod by me ars coneci and comdete. r am awar6 thal any false sr.tements wil t6ad ro my
apdirioo bing rg.1ed io 0t6 annLln'nl ol a Vsa aheady g.a.td and may also r$de. me liaus to Drceqriion urider lh ta$/ ol th M.nbr State
which deab wnh he apdication.

I urld.iale lo l6ave th ierritay of lhe Membr Slats bfde lh expiry of ihe vis5, if grantod I havs ben inlo.med th pcsssioo ot a vM is (iy ore ot
ihe prerequisdes to niry onto the Eurcpean tnltory ol the renber Slares. The mre fact that a visa has bn granrd to me do6 not mean ihat I wjl b
enti!6d to comPensaiion iilfailto @mpry w(h lhe rclevanl provislons olAnid 5(1) or Regulaiion (EC) No 5.22006 (Schercen borders Code) and tam
tsElde lBtusd enry It p.erequisil6 to. ntry wil be checked as6in on nlry into Europan lenitory of rhe Me.nber Slats
47, Place.nd dat6 erurJ uLs-lr 118. Signature (ror mlnors, slgnatu16 of custodian/guardian)
(
-t'ir JJ J" a, e, (d l 8 y .li"r) r"-n! Jr!!r 3lJ!l eMr *L- arr,'
Belehruno nach I 54 Abs. 2 Nr. 8 i.V.m. I 53 Aufenthc

Ein Auslander kann ausgewiesen werden, wenn er falsche oder unvollstiindige Angaben zur
Erlangung eines deutschen Aufenthaltstitels oder eines Schengen-Visums macht.

Der Antragsteller ist verpflichtet, alle Angaben nach bestem Wissen und Cewissen zu machen.
Sofern er Angaben verweigert oder bewusst falsch oder unvollstandig macht, kann dies zur
Folge haben, dass der Visumantrag abgelehnt bzw. der Antragsteller aus Deutschland
ausgewiesen wird, sofern ein Visum bereits erteilt wurde. Durch die Unterschrift bestetigt der
Antragsteller, dass er vor der Antragstellung iiber die Rechtsfolgen verweigerter, falscher oder
unvollstindiger Angaben im Visumverfahren belehn worden ist.

Ort, Datum Unterschrift

Informstion provided to applicants pursuant to Section 54 (2) 8 ill coniunction with

Section 53 ofthe Residence Act)

A foreigner can be expelled ifhe or she has fumished false or incomplete information in order
to gain a German residence permit or a Schengen visa.

The applicant is obliged to provide all informarion ro rhe best ofhis or her knowledge and
belief. lfhe or she refuses to provide data or knowingly furnishes false or incomplete
information, the visa application may be refused or, ifa visa has already been issued, the
applicant may be expelled from Cermany. In signing this document, the applicant certifies
that, before submitting the application, he or she was informed ofthe legal consequences of
refxsing to provide data or fumishing false or incomplete information in the visa application
process.

Place, date Signature

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