OBRAZAC 1

Ovaj obrazac se ne naplauje. / This application form is free. / Le prsent formulaire est dlivr gratuitement. prijamni tambilj stamp of receipt cachet de reception

fotograja photo photo 35 x 45 mm

ZAHTJEV ZA VIZU VISA APPLICATION DEMANDE DU VISA

IZDAVANJE ISSUANCE DLIVRANCE
c

PRODULJENJE EXTENSION PROROGATION

1.

Prezime (bive odnosno roeno prezime) Surname (also maiden surname for married women) Nom (aussi nom de jeune lle pour les femmes marries) Ime / Given name(s) / Prnom(s) Ime oca i majke / Given name(s) of father and mother / Prnom(s) du pre et de la mre Datum roenja / Date of birth / Date de naissance Mjesto i drava roenja / Place and country of birth / Lieu et pays de naissance Sadanje dravljanstvo/dravljanstva / Current nationality/nationalities / Nationalit/nationalits actuelle Dravljanstvo pri roenju / Original nationality (nationality at birth) / Nationalit dorigine ( la naissance) Spol / Sex / Sexe Brano stanje Marital status Situation de familiale c c c c c c c Muki / Male / Masculin Neoenjen/neudana / Single / Clibataire Oenjen/udana / Married / Marri(e) Razveden(a) / Divorced / Divorc(e) Odvojen(a) / Separated / Spar(e) Udovac(a) / Widow(er) / Veuf(veuve) Ostalo / Other / Autre ................................................................................ c enski / Female / Fminin

Popunjava slubena osoba To be lled out by ofcial person

2. 3. 4. 5. 6. 7. 8. 9.

A remplir par le fontionnaire

Datum obrade zahtjeva Date application Date dintroduction de la demande

....................................
Potpis slubene osobe File handled by Responsable du dossier

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Priloena dokumentacija Supporting documents Documents justicatifs Valjana putovnica Valid passport Passeport en cours de validit

c Novana sredstva
za uzdravanje Financial means Moyens nanciers

10.

Vrsta putne isprave Type of passport Type de passeport

c c c c

Obina putovnica / National passport / Passeport ordinaire Diplomatska putovnica / Diplomatic passport / Passeport diplomatique Slubena putovnica / Service passport / Passeport ofciel Putna isprava po Konvenciji iz 1951. Travel document (1951 Convention) Document de voyage selon la Convention de 1951 Putna isprava po Konvenciji iz 1954. Travel document (1954 Convention) Document de voyage selon la Convention de 1954 Druga putna isprava (navesti koja) Other travel document (please specify) Autre document de voyage (Priere de specier lequel) ............................................................................... ....

c Poziv
Invitation Invitation

c Nain putovanja
Means of transport Moyens de transport

c Putno osiguranje
Travel insurance Assurance voyage

11. 12. 13. 14. 15. 16.

Broj putne isprave / Number of passport / Numero du document de voyage Izdana od / Issued by / Delivre par Datum izdavanja / Date of issue / Date de delivrance Rok valjanosti / Valid until / Date dexpiration de la validit Broj osobne iskaznice (nije obavezno) / ID-number (optional) / Numero de carte d identite (facultatif) Ako boravite u zemlji koja nije vaa zemlja podrijetla, imate li doputenje vratiti se? If you reside in a country other than your country of origin, have you permission to return to that country? Si vous residez dans un pays autre que votre pays dorigine, etes-vous autorise(e) a retourner dans ce pays? c NE / NO / NON c DA (broj i valjanost) YES (number and validity)

c Drugo
Other Autres Viza Visa

c Odbijena
Refused Refus

c Odobrena
Approved Accord

OUI (Numero et validit)

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17. 18.

Zanimanje / Current occupation / Occupation actuelle Poslodavac (naziv, adresa, broj telefona), za studente/uenike naziv i adresa kole Employer and employers address and telephone number. For students, name and address of school. Employer, adresse et numero de telephone de l`employeur. Pour les etudiants, nom et adresse de l`etablissement denseignement.

Vrsta vize Type of visa Type de visa

c A c B c C
Broj ulazaka Number of entries Nombre dentres

19. 20.

Drava odredita / Main destination / Destination principale Druge vize izdane u posljednje tri godine i razdoblje njihove valjanosti Other visas (issued during the past three years) and their period of validity Autres visas (dlivrs au cours des trois dernires annes) et leur dure de validit U sluaju tranzita, imate li dozvolu ulaska u treu zemlju? In the case of transit, have you an entry permit for the nal country of destination? En cas de transit, avez-vous une autorisation d`entre dans le pays de destination nale? Vrsta vize Type of visa Type de visa c Zrakoplovno tranzitna (A) / Airport transit (A) / Transit aroportuaire (A) c Tranzitna (B) / Transit (B) / Transit (B) c Putna (C) / Travel (C) / De voyage (C) c Jedan / One / Une c Dva / Two / Deux c Neogranien / Multiple / Multiples ................ dana / days / jours

c 1 c 2 c N
Rok valjanosti Period of validity Priode de validit od from du ........................... do to au ............................ Trajanje boravka Duration of stay Dure du sjour Dana Days Jours ........................ Napomene Remarks Remarques

21.

22.

23.

Broj ulazaka Number of entries Nombre dentres demandes

24. 25.

Trajanje boravka / Duration of stay / Dure de sjour Svrha putovanja Purpose of travel But de voyage c c c c c

c Turizam / Tourism / Tourisme Slubeno / Ofcial / Ofcielle c Poslovno / Business / Affairs Kultura/sport / Cultural/Sports / Culture/sport Privatni posjet / Visit to Family or Friends / Visite la famille ou ou des amis Zdravstveni razlozi / Medical reasons / Raisons mdicales Ostalo (molimo navesti) / Other (please specify) / Autres ( prciser)

.................................... .................................... .................................... .................................... ....................................

.......................................................................................................... 26. Fizika ili pravna osoba koju posjeujete (ime, adresa, broj telefona i faksa, e-mail) Natural or legal person you are visiting (Name, address, telephone) Personne physique ou personne civile que vous visitez (Nom, adresse, tlphone)

27.

Adresa boravka u Republici Hrvatskoj Address where you will be staying in the Republic of Croatia Adresse du sjour de la Rpublique de Croatie Tko snosi trokove putovanja i boravka? Who is paying for your costs of travelling and for your costs of living during your stay? Qui nance le voyage et subvient vos besoins durant votre sjour? c Osobno / Myself / Moi-meme c Fizika osoba/pozivatelj / Host person(s) / Hote(s) c Pravna osoba (koja i kako) / Host company (state who and how) / Socit hote (indiquer les nom et modalit)s ..............................................................................................................................................

.................................... .................................... ....................................

28.

29.

Novana sredstva za uzdravanje Means of support during your stay Moyens de nancement utiliss au cours du sjour

c c c c c c

Gotovina / Cash / Argent liquide Putniki ekovi / Travellers cheques / Cheques de voyage Kreditne kartice / Credit cards / Cartes de crdit Smjetaj / Accomodation / Hbergement Drugo / Other / Autres Putno i/ili zdravstveno osiguranje. Vrijedi do Travel and/or health insurance. Valid until Assurance voyage et/ou assurance maladie. Valable jusqu`au: ...........................................................................................

30. 31. 32.

Datum dolaska / Date of arrival / Date darrive Datum odlaska / Date of departure / Date de dpart Nain putovanja / Means of transport / Moyens de transport

33. 34. 35.

Ime branog druga / Spouses rst name / Nom de famillie du conjoit Prezime branog druga / Spouses family name / Nom de famille du conjoit Prezime branog druga pri roenju Spouses family name at birth Nom de famille du conjoit la naissance Datum roenja branog druga / Spouses date of birth / Date de naissance du conjoint Mjesto roenja branog druga / Spouse place of birth / Lieu de naissance du conjoit Djeca Children Enfants Ime i prezime Name and rst name Nom - Prnom Datum roenja Date of birth Date de naissance

36. 37. 38.

1. ................................................................................................................................................................. 2. ................................................................................................................................................................. 3. ............................................................................................................................................................. 39. Pri punoj svijesti izjavljujem i pristajem na sljedee: svi moji osobni podaci koji se navode na ovom obrascu zahtjeva za vizu proslijedit e se, ako je potrebno, na rjeavanje i provjeru nadlenim tijelima Republike Hrvatske, u svrhu odluivanja o ovome zahtjevu. Na moje izriito traenje, tijelo koje odluuje o mom zahtjevu obavijestit e me o nainu, propisanom hrvatskim zakonodavstvom, na koji mogu ostvariti pravo na provjeru svojih osobnih podataka, te njihovu izmjenu ili brisanje, osobito ako bi bili netoni. Izjavljujem da su svi podaci koje sam naveo u ovom obrascu istiniti i toni. Svjestan sam da e bilo koja lana izjava imati za posljedicu odbijanje mog zahtjeva ili ponitenje ve izdane vize. Obvezujem se da u napustiti dravno podruje Republike Hrvatske po isteku roka valjanosti vize, ako mi viza bude izdana. Obavijeten sam da je viza samo jedan od uvjeta za ulazak na dravno podruje Republike Hrvatske. Svi uvjeti za ulazak bit e ponovno provjereni pri ulasku na dravno podruje Republike Hrvatske. I am aware of and consent to the following: any personal dana concerning me which appear on this visa application form will be supplied to the relevant authorities of the Republic of Croatia and processed by those authorities. At my express request, the consular authority processing my application will inform me of the manner in which i may excersise my right to check the personal dana concerning me and have them altered or deleted, in particular, should they be inaccurate. 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. I undertake to leave the territory of the Republic of Croatia 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 the territory of the Republic of Croatia. The prerequisites for entry will be checked again on entry into the Republic of Croatia.

En connaissance de cause, jaccepte que les donnes caractre personnel me concernat qui gurent das le prsent formulaire de demande de visa soient communiqes aux autorits comptentes de la Rpublique de Croatia pour que celles-ci puissent en prendre dcision. A ma demande expresse, l autorit consulaire qui a instruit ma demande minformera de la manire dont je peux exercer mon droit vrier les donnes caractre personnel me concernat et les faire modier ou supprimer, notamment si elles sont inexactes. Je dclare qu ma connaissance toutes les indications, que jai fournies sont correctes te compltes. Je suis conscient de ce que toute fausse dclaration entrainera le rejet de ma demande ou lannulation du visas sil a dja t dlivre. Je mengage abandonner le territoire national de la Rpublique de Croatie pour lechance de la priode de validit du visa, au cas ou le visa me serait accord. Je suis galement inform (e) que le visa nest quune condition pralable pour entrer en territoire de la Rpublique de Croatie. Toutes les conditions pralables seront vries de nouveau loccasion de lentre en territoire national de la Rpublique de Croatie.
40. Adresa podnositelja zahtjeva / Applicants home address / Domicile dorigine du demandeur

41. 42. 44.

Broj telefona podnositelja zahtjeva / Telephone number / Numro de tlphone Datum i mjesto / Place and date / Lieu et date Potpis podnositelja zahtjeva (za maloljetne zakonskog zastupnika) Signature (for minors, signature of custodian/guardian) Signature (pour les mineurs, signature de la personne qui en a la garde/ la tutelle)