29.05.

2016

SystemZdalnejRejestracji

Termsandconditions

eKonsulat
Homepage>Kishinev>Visa>SchengenVisaRegisterform>Registrationofvisaapplication

APPLICATIONFORSCHENGENVISA
FieldsNo:1,2,3,5,11,13,16,31,34shouldbefilledinbyusingtheLatinalphabetlettersonly(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).Anyerroneousentryshallmaketheapplication
void.

Visa

NationalVisaRegisterform
SchengenVisaRegister
form

Personaldata
1.Surname(s)(familyname(s))Fieldrequired

Visits

PolishCard
Cancelappointment

2.Surname(s)atbirth(previouslyusedsurname(s))Fieldrequired
3.Firstname(s)Fieldrequired

4.Dateofbirth(yearmonthday)Fieldrequired
5.PlaceofbirthFieldrequired
6.CountryofbirthFieldrequired

7.Currentnationality/iesFieldrequired

Originalnationality(nationalityatbirth)Fieldrequired

8.SexFieldrequired

9.MartialstatusFieldrequired

Male

Single

Female

Married
Separated
Divorced
Widow(er)
Other

Nationalidentitynumber

Passportdata
12.TypeoftraveldocumentFieldrequired
Ordinarypassport
Diplomaticpassport
Servicepassport
Officialpassport
Specialpassport
Othertraveldocument(pleasespecify):

13.Numberoftraveldocument
Fieldrequired
14.Dateofissue(yearmonthday)

15.Validuntil(yearmonthday)

Fieldrequired

Fieldrequired

16.Issuedby

Fieldrequired

10.Inthecaseofminors:Surname,firstname,address(ifdifferentfromapplicants)and
nationalityofparentalauthority/legalguardian
doesnotapply
Nationality
Fieldrequired

Firstname

Fieldrequired

Surname

Fieldrequired

Country
Fieldrequired

State/province
Place
Fieldrequired
Postalcode
Fieldrequired

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Address
Fieldrequired

more
17.Applicantshomeaddressandemailaddress

CountryFieldrequired
State/provinceField
required
PlaceFieldrequired
PostalcodeField
required
AddressFieldrequired

Currentemailaddress.
EmailFieldrequired OtheremailaddressesthantheoneprovidedintheVISAApplicationFormshallnotbe
usedwhencontactinganapplicant.
PhoneareacodeField
required
PhonenumberField
required
18.Residenceinacountryotherthanthecountryofcurrentnationality
No
Yes.Residencepermitorequivalent
Fieldrequired
Number
Expirydate

indefinitely

*19.Currentoccupation

Student,trainee

*20.Employerandemployersaddressandphonenumber.Forstudents,nameandaddressofschool
Employer
School

MOLDOVA

State
State/province
Place
Postalcode
Address
Phoneareacode
Phone
Name

Fieldrequired

Fieldrequired

Fieldrequired

Fieldrequired
Fieldrequired
Fieldrequired

Fieldrequired

Email

Faxareacode
Numberoffax
21.Mainpurpose(s)ofthejourney:
Tourism
Business
Visittofamilyorfriends
Cultural
Sports
Officialvisit
Medicalreason
Study
Transit
Airporttransit
Other(pleasespecify):

Fieldrequired

Detailsregardingtravelarrangements.
22.Destinationcountry

POLAND
24.Numberofentriesrequested
Singleentry
Twoentries

23.MemberStateoffirstentry

25.Durationofstay:
Visarequestedfor

days(<=90)

Fieldrequired

Multipleentries

29.IntendeddateofarrivalintheSchengenarea

30.IntendeddateofdeparturefromtheSchengen

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area
Fieldrequired

Fieldrequired

Thefieldsmarkedwith*shallnotbefilledinbyfamilymembersofEU,EEAorCHcitizens(spouse,childordependent
ascendant)whileexercisingtheirrighttofreemovement.FamilymembersofEU,EEAorCHcitizensshallpresent
documentstoprovethisrelationshipandfillinfieldsNo34and35.
26.OtherSchengenvisas(issuedwithinthepast3years)andtheirperiodofvalidity:
No
Yes.Date(s)ofvalidity
from(yearmonthday):

to(yearmonthday):

more

27.FingerprintscollectedpreviouslyforthepurposeofapplyingforaSchengenvisa
No
Yes

doesnotapply
28.Entrypermitforthefinalcountryofdestination,whereapplicable
Issuedby:

Fieldrequired

Validfrom

Fieldrequired

validuntil

Fieldrequired

Dataofreceivingperson
*31,32.NameofhostpersonorcompanyintheSchengenstatesandcontactperson
inhostcompany.Ifnotapplicablenameofhotelortemporaryaddressinthe
Schengenstates:
Person

Type

Company
Name
Firstname
Surname

Country

Place
Postalcode
Phoneareacode
Phonenumber
Faxareacode
Numberoffax
Address
Housenumber
Flatnumber
Emailaddress

Dataofpersoncoveringexpenses
*33.Costoftravellingandlivingduringtheapplicantsstayiscovered
bytheapplicanthimself/herself
Byasponsor(host,company,organisation),pleasespecify
referredtoinfield31or32
other(pleasespecify)

Meansofsupportduringyourstay
Cash
Travellerscheques
Creditcards
Accommodation
Prepaidtransport
Allexpensescoveredduringthestay
Other:
Traveland/orhealthinsurance.Validuntil:

EUcitizendata
34.PersonaldataoftheEUorEEAcitizenyoudependon.Thisquestionshouldbeansweredonlybyfamily
membersofEUorEEAcitizens.
doesnotapply
Surname
Dateofbirth

Firstname

Fieldrequired

Fieldrequired

Numberofpassport

https://secure.ekonsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=D296F902E79E46DF913D91B1320524C8

Fieldrequired

Fieldrequired

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Nationality Fieldrequired
spouse
child
Relationship:

grandchild
dependentascendant
Fieldrequired

Applicant'sdata
Fieldrequired
Iamawarethatthevisafeeisnotrefundedifthevisaisrefused.
Fieldrequired
Applicableincaseamultipleentryvisaisappliedfor(cf.FieldNo24):Iamawareoftheneedtohaveanadequate
travelmedicalinsuranceformyfirststayandanysubsequentvisitstotheterritoryofMemberStates.
Fieldrequired
Iamawareofandconsenttothefollowing:thecollectionofthedatarequiredbythisapplicationformandthe
takingofmyphotographand,ifapplicable,thetakingoffingerprints,aremandatoryfortheexaminationofthevisa
applicationandanypersonaldataconcerningmewhichappearonthevisaapplicationform,aswellasmy
fingerprintsandmyphotographwillbesuppliedtotherelevantauthoritiesoftheMemberStatesandprocessedby
thoseauthorities,forthepurposesofadecisiononmyvisaapplication.Suchdataaswellasdataconcerningthe
decisiontakenonmyapplicationoradecisionwhethertoannul,revokeorextendavisaissuedwillbeenteredinto,
andstoredintheVisaInformationSysetm(VIS)()foramaximumperiodoffiveyears,duringwhichitwillbe
accessibletothevisaauthoritiesandtheauthoritiescompetentforcarryingoutchecksonvisasatexternalborders
andwithintheMemberStates,immigrationandasylumauthoritiesintheMemberStatesforthepurposesofverifying
whethertheconditionforthelegalentryinto,stayandresidenceontheterritoryoftheMemberStatesarefulfilled,of
identifyingpersonswhodonotorwhonolongerfulfiltheseconditions,ofexamininganasylumapplicatonandof
determiningresponsibilityfosuchexamination.Undercertainconditionsthedatawillbealsoavailabletodesignated
authoritiesoftheMemberStatesandtoEuropolforthepurposeoftheprevention,detectionandinvestigationof
terroristoffencesandofotherseriouscriminaloffences.TheauthorityoftheMemberStateresponsibleforprocessing
thedatais:CentralnyOrganTechnicznyKSI,KomendaGwnaPolicji,Puawska148/150,02624Warszawa.Iam
awarethatIhavetherighttoobtaininanyoftheMemberStatesnotificationofthedatarelatingtomerecordedinthe
VISandoftheMemberStatewhichtransmittedthedata,andtorequestthatdatarelatingtomewhichareinaccurate
becorrectedandthatdatarelatingtomeprocessedunlawfullybedeleted.Atmyexpressrequest,theauthority
examiningmyapplicationwillinformmeofthemannerinwhichImayexercisemyrighttocheckthepersonaldata
concerningmeandhavethemcorrectedordeleted,includingtherelatedremediesaccordingtothenationallawofthe
Stateconcerned.ThenationalsupervisoryauthorityofthatMemberStatewillhearclaimsconcerningtheprotectionof
personaldata:GeneralnyInspektorOchronyDanychOsobowych,ul.Stawki2,00193Warszawa.Ideclarethattothe
bestofmyknowledgeallparticularssuppliedbymearecorrectandcomplete.Iamawarethatanyfalsestatements
willleadtomyapplicationbeingrejectedortotheannulmentofavisaalreadygrantedanymayalsorendermeliable
toprosecutionunderthelawoftheMemberStatewhichdealswiththeapplication.Iundertaketoleavetheterritoryof
theMemberStatesbeforetheexpiryofthevisa,ifgranted.Ihavebeeninformedthatpossessionofavisaisonlyone
oftheprerequisitesforentryintotheEuropeanterritoryoftheMemberStates.Themerefactthatavisahasbeen
grantedtomedoesnotmeanthatIwillbeentitledtocompensationifIfailtocomplywiththerelevantprovisionsof
Article5(1)ofRegulation(EC)No562/2006(SchengenBordersCode)andIamtereforerefusedentry.The
prerequisitesforentrywillbecheckedagainonentryintotheEuropeanterritoryoftheMemberStates.

*Questionsmarkedwith*maybeomittedbyfamilymembersofEUorEEAcitizens(spouse,child,ordependent
ascendant).FamilymembersofEUorEEAcitizenshavetopresentdocumentsprovingthisrelationship.
PleasemakesurethatthedataenteredintheVisaApplicationFormarecorrectandpressSAVEbuttontoconfirmit.
PressCORRECTbuttonifyouneedtoamendanydatayouhaveenteredintheApplicationForm.Anyerroneousentry
shallmaketheapplicationvoid.
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