Вы находитесь на странице: 1из 4

ANEXA 8

Operator de date cu caracter personal notificat sub numarul 5285

Formular de cerere pentru viz de scurt edere


TAMPILA AMBASADEI/CONSULATULUI
FOTOGRAFIE
3/4

Solicitare de viz
Application for Visa


Formular gratuit/This application form is free/
TIP DE VIZA: A; B; C

1. Numele/Surname(s) (family name(s)) /

FOR EMBASSY /

IONESCU

CONSULATE USE
ONLY

2. Numele la natere/ Surname(s) at birth (earlier family name(s))/

GEORGESCU
Data solicitrii :

3. Prenume/First names (given names )/

MARIA
4. Data naterii/Date of birth /

Document procesat de :

5. CNP/ ID- /

28.07.1968
6. Locul i ara naterii/ Place and country of birth /

Documente doveditoare:

CHISINAU, REPUBLICA MOLDOVA


7.

8.

Cetenia prezent/Current nationality/ies /

MOLDOVENEASCA

MOLDOVENEASCA
10.

Sexul/Sex /

Brbtesc/Male/

Cetenia la natere/Original nationality (nationality at birth)/


Statut civil/Marital status/ :

Cstorit/Married//
Separat/Separated/

Mijloace financiare
Invitaie
Mijloace de transport
Bilet de calatorie
Asigurare de sntate
Dovada asigurarii
conditiilor de cazare
Exceptii: (se va completa

Celibatar/Single//

Femeiesc/Female/

Paaport valabil

Divorat/Divorced/ ()

Vduv()/Widow(er)/ (- /-)

in functie de documentele
prezentate de solicitant, in
conformitate cu art.40 din
O.U.G.194/2002))

Altele/Other/

11. Prenumele tatlui/Fathers name/

12. Prenumele mamei/Mothers name/

ION

MARIA

13. Document de cltorie/Type of passport/ :


Paaport diplomatic/Diplomatic passport/

Paaport

turistic/National passport/ .

Paaport de serviciu/Service passport

Document de cltorie pentru refugiai/Travel document (1951 Conv.)

Paaport pentru strini/Aliens passport


Carnet de marinar/Seamans passport/
Altele (specificai)/Other travel document (please specify):
.......................................................................................................

14. Nr. de paaport/Number of passport/

15. Emis de/Issued by/

B1234

REPUBLICA MOLDOVA

16. Data emiterii/Date of issue (d/m/y)/

17. Valabil pn la/Valid until (d/m/y) /

27.02.2010
18.

27.02.2020

Dac avei domiciliul n alt stat dect cel de origine, v este permis s v rentoarcei n acest stat/If you reside in a country
other than your country of origin, have you permission to return to that country? / ... ,
...?

Nu/No/

Da (numrul i valabilitatea permisiunii)/Yes, (number and validity)/ (


) ...

*19.

Funcia ocupat n prezent/ Current occupation/

PROFESOR
*20.

Angajatorul, adresa acestuia i nr. de tel. Pentru elevi i studeni, denumirea i adresa instituiei de nvmnt/Employer
and employers address and telephone number. For students, name and address of school./ ,
.,

Viza :
Refuzat
Acordat

LICEUL VASILE ALECSANDRI CHISINAU


21. Destinaia principal/Main destination

BUCURESTI

22.

Tipul de viz/Type of Visa/



Tranzit aeroportuar/Airport transit/

23.

Viz/Visa/

Individual/Individual/

Tipul de viz :
A
B

29. Scopul ederii n Romnia/Purpose of travel /

( )

Misiune (C/M)/Official/

Afaceri (C/A)/Business/

Transport (C/TR)/ Transportation)/

Turism (C/TU)/Tourism/

Vizit (C/VV)/Visit to Family or Friends/

Activiti sportive (C/SP) /Sport/


Activiti culturale, tiinifice, umanitare, tratament medical de


scurta durata care nu contravin legilor romne (C/ZA)/ Other activities /

*30.

Data sosirii/ Date of arrival (day-month-year)/


*31.

Data plecrii/Date of departure (day-month-year)


15.09.2010

01.10.2010

*32.

*33.

Punctul de intrare, sau traseul de tranzit/Border of first


entry or transit route/

ALBITA
*34.

Mijloc de transport/Means of transport/

AUTOTURISM

Denumirea firmei romne de contact i a persoanei responsabile n cadrul acesteia. n absen, denumirea hotelului sau
adresa temporar n Romnia/ Name of host or company in Romania and contact person in host company. If not applicable,
give name of hotel or temporary address in Romania./
. , .

BUCURESTI, STRADA LEOVA NR. 7


Nume/Name/

Tel. i fax/phone and fax no./.


GEORGE GEORGESCU

0040123456789

Adresa complet/Full address/

e-mail/e-mail address/

BUCURESTI, STRADA LEOVA NR. 7


*35.

Cine suport cheltuielile de deplasare i de edere n Romnia/Who is paying for your cost of travelling and for your costs
of living during your stay?/ ,
Subsemnatul/Myself/
Persoan fizic romn/Host person(s)/

Persoan juridic romn(numii cine i anexai documente doveditoare)/Host company. (State who and how and present
corresponding documentation)/ :(
) : .......................................................................................................................................................................................
...............................................................................................................................................................................................................
....................
*36. Modaliti de ntreinere n Romnia/Means of support during your stay /
Cash/

Cecuri de cltorie/Travellers' cheques/


Cazare pltit/Accommodation /

Cri de credit/Credit cards/

Altele/Other:
Asigurare medical valabil pn la/Travel and/or health insurance. Valid until: ,
......................................................................................................................................

37.

Numele soului(soiei)/Spouses family name/


/

IONESCU
39.

Prenumele soului(soiei)/
Spouses first name /
/

VICTOR
42.

38. Numele la natere al soului(soiei)/ Spouses family


name at birth /
/

IONESCU
40.

Data de natere a soului (soiei)/


Spouses date of birth (d/m/y) /
/

17.05.1965

41. Locul de natere al soului(soiei)/


Spouses place of birth /

/

IALOVENI, REPUBLICA
MOLDOVA

Copii (se vor completa solicitri separate pentru cei care dein paaport individual)/Children (Applications must be
submitted separately for each passport)/ ( ,
)

Nume/Name /

Prenume/First name /

Data naterii/Date of birth /

1 ALINA
.....................................................................................................................................................................................................

2 MARIUS...............................................................................................................................................................................
3 ............................................................................................................................................................................................................
.

FOR EMBASSY / CONSULATE


USE ONLY

44.

Daca aveti alte rude in Romania?/If you have any relatives in Romania?/
?

NU ESTE CAZUL
45.

Am luat la cunotin urmtoarele: toate datele personale cu privire la subsemnatul(a) care apar n prezentul formular vor fi puse la
dispoziia autoritilor romne competente i procesate de ctre acestea, dup caz, n scopul lurii unei decizii cu privire la prezenta solicitare de
viz. Aceste date pot fi introduse i stocate n bazele de date accesibile autoritilor romne competente.
Urmare solicitrii exprese a subsemnatului, autoritile consulare menite s proceseze prezenta solicitare m vor informa cu privire la la
modalitatea n care mi pot exercita dreptul de a verifica datele personale furnizate, de a dispune modificarea sau ndeprtarea lor, dac se
dovedesc incorecte, n conformitate cu prevederile legislaiei n vigoare n Romnia.
Declar c, dup tiina mea, toate datele furnizate sunt corecte i complete.
Declar c am cunotin de faptul c orice date false furnizate conduc la respingerea prezentei solicitri sau la anularea vizei emise n baza
acestora i pot duce la declanarea urmririi mele penale n conformitate cu legea romn. M oblig s prsesc teritoriul Romniei la expirarea
vizei ce mi-a fost acordat.
Am fost informat c deinerea vizei nu reprezint dect una dintre condiiile de ndeplinit pentru intrarea n Romnia. Simpla eliberare a vizei nu
presupune faptul c sunt ndreptit() la primirea unor compensaii dac nu ndeplinesc condiiile prevzute la Capitolul II (Dispoziii generale
privind intrarea, ederea i ieirea strinilor) al OUG 194/2002 i mi este refuzat intrarea n Romnia. ndeplinirea condiiilor de intrare va fi
supus verificrii la momentul intrrii pe teritoriul Romniei./
Sunt de accord cu prelucrarea datelor prezentate n conformitate cu Legea 677/2001.
I am aware of and consent to the following: any personal data concerning me which appear on this visa application form will be supplied to the
relevant authorities in Romania and processed by those authorities, if necessary, for the purposes of a decision on my visa application. Such data
may be input into, and stored in, databases accessible to the relevant authorities in Romania.
At my express request, the consular authority processing 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 altered or deleted, in particular, should they be inaccurate, in accordance with the national law of
the state concerned.
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 Romanian law which deals with the application.
I undertake to leave the territory of Romania upon 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 Schengen 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 Chapter II (General provisions regarding entry, stay and exit of aliens) of GEO no.194/2002 and am thus refused entry. The prerequisites for
entry will be checked again on entry into the territory of Romania.
I agree with processing of data presented in according with Law no. 677/2001.
() : , ,
,
. , .
,
,
.
, , .
, ,
,
. .
, , .
, - ,
II- ( , ) 194/2002
.
.
, 677/2001.

46. Adresa de domiciliu a solicitantului/Applicants home address/

47. Nr.de tel./Phone no./


.

CHISINAU, STRADA VALERIU ENESCU 19/1


48.

Dat la (locul i data)/Place and date (d/m/y)/


( )

CHISINAU, 01.09.2010

012345678

49. Semntura (pentru minori, semntura reprezentantului


legal)/Signature (for minors, signature of custodian/guardian) /
( ,
)

(*) Rubricile nsoite de (*) nu trebuie completate de membrii familiei resortisanilor UE sau SEE (so, soie, copil sau
ascendent dependent). Membrii familiei resortisanilor UE sau SEE trebuie sa prezinte documentele care dovedesc relaia de
rudenie.
(*) The questions marked with (*) do not have to be answered by family members of EU or EEA citizens (spouse, child or
dependant ascendant). Family members of EU or EEA citizens have to present documents to prove this relationship.
(*) (*)
( , , ).

.