OBRAZAC 1

Ovaj obrazac se ne naplauje. /

This application form is free.

/ Le prsent formulaire est dlivr gratuitement.

prijemni tambilj
stamp of receipt
cachet de reception

fotografija
photo
photo
35 x 45 mm

ZAHTJEV ZA VIZU

VISA APPLICATION
DEMANDE DU VISA
IZDAVANJE

PRODUENJE

ISSUANCE
DLIVRANCE
1.

EXTENSION
PROROGATION

Prezime (bive odnosno roeno prezime)

Surname (also maiden surname for married women)
Nom (aussi nom de jeune fille pour les femmes marries)

Popunjava slubeno
lice

2.

Ime / Given name(s) / Prnom(s)

To be filled out by official

person

3.

Ime oca i majke / Given name(s) of father and mother / Prnom(s) du pre et de la mre

A remplir par le
fontionnaire

4.

Datum roenja / Date of birth / Date de naissance

5.

Mjesto i drava roenja / Place and country of birth / Lieu et pays de naissance

6.

Sadanje dravljanstvo/ dravljanstva /

7.

Dravljanstvo pri roenju /

8.

Pol / Sex / Sexe

Muki / Male / Masculin

9.

Brano stanje
Marital status
Situation de familiale

Single / Clibataire
Neoenjen/neudata /
Married / Marri(e)
Oenjen/udata /
Razveden(a) / Divorced/ Divorc(e)
Odvojen(a) / Separated/ Spar(e)
Udovac(a) / Widow(er)/ Veuf(veuve)
Ostalo / Other / Autre

Datum obrade zahtjeva

Date application
Date dintroduction de la
demande

Current nationality/nationalities / Nationalit/nationalits actuelle

Original nationality (nationality at birth) / Nationalit dorigine ( la naissance)

enski / Female / Fminin

Vrsta putne isprave

Type of passport
Type de passeport

Passeport en cours de validit

Obian paso / National passport / Passeport ordinaire

Diplomatski paso / Diplomatic passport / Passeport diplomatique
Service passport / Passeport officiel
Slubeni paso

Putna isprava po Konvenciji iz 1951.

Travel document (1951 Convention)
Document de voyage selon la Convention de 1951

Nain putovanja

............................................................................... ...
.
Number of passport / Numero du document de voyage

12.

Izdata od /

13.

Datum izdavanja /

Date of issue / Date de delivrance

14.

Rok vaenja /

Valid until / Date dexpiration de la validit

15.

Broj line karte (nije obavezno) /

16.

Ako boravite u zemlji koja nije vaa zemlja porijekla, imate li dozvolu za povratak ?

Issued by / Delivre par

ID-number (optional) / Numero de carte d identite (facultatif)

DA (broj i vaenje)

YES (number and validity)

Means of transport
Moyens de transport

Putno osiguranje
Travel insurance
Assurance voyage

Drugo
Other
Autres
Viza
Visa

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?

NE / NO / NON

za izdravanje
Financial means
Moyens financiers

Invitation
Invitation

Druga putna isprava (navesti koja)

Other travel document (please specify)
Autre document de voyage (Priere de specifier lequel)

Broj putne isprave /

Novana sredstva

Poziv

Putna isprava po Konvenciji iz 1954.

Travel document (1954 Convention)
Document de voyage selon la Convention de 1954

11.

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

Vaei paso
Valid passport

Potpis slubenog lica

File handled by
Responsable du
dossier

Priloena dokumentacija
Supporting documents
Documents justificatifs

................................................................................
10.

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

OUI (Numero et validit)

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

Odbijena
Refused
Refus

Odobrena
Approved
Accord

17.

Zanimanje /

18.

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.

19.

Drava odredita /

20.

Druge vize izdate u posljednje tri godine i period njihovog vaenja

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

Current occupation / Occupation actuelle

Main destination / Destination principale

Broj ulazaka
Number of entries
Nombre dentres

1

2

N

21.

U sluaju tranzita, imate li dozvolu ulaska u treu zemlju?

In the case of transit, have you an entry permit for the final country of destination?
En cas de transit, avez-vous une autorisation d`entre dans le pays de destination finale?

22

Vrsta vize
Type of visa
Type de visa

Aerodromsko-tranzitna (A) /
Airport transit (A) / Transit aroportuaire (A)

Tranzitna (B) / Transit (B) / Transit (B)

Putna (C) / Travel (C) / De voyage (C)

Viza na dui boravak (D)
/ Long stay visa (D) / Visa pour long sjour (D)
Individualna

23.

Broj ulazaka
Number of entries
Nombre dentres demandes

24.

Trajanje boravka

25.

Svrha putovanja
Purpose of travel
But de voyage

/ Individual / Individuel

/ Collective / Collectif

Jedan / One / Une

Dva / Two / Deux

Neogranien / Multiple / Multiples

/ Duration of stay / Dure de sjour

Kolektivna

................ dana / days / jours

Turizam / Tourism / Tourisme

Slubeno / Official / Officielle

Poslovno / Business / Affairs
Kultura/sport / Cultural/Sports / Culture/sport
Privatna posjeta / 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.

Vrsta vize
Type of visa
Type de visa

A

B

C

D

Fiziko ili pravno lice koje posjeujete (ime, adresa, broj telefona i faksa, e-mail)
Natural or legal person you are visiting (Name, address, telephone, e-mail)
Personne physique ou personne civile que vous visitez (Nom, adresse, tlphone, e-mail)

Rok vaenja
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
....................................
....................................
....................................
....................................

27.

28.

Adresa boravka u Crnoj Gori

Address where you will be staying in the Montenegro
Adresse du sjour de la Montngro
Ko snosi trokove putovanja i boravka?
Who is paying for your costs of travelling and for your costs of living during your stay?
Qui finance le voyage et subvient vos besoins durant votre sjour?

Fiziko lice/pozivalac / Host person(s) / Hote(s)

Lino
/ Myself / Moi-meme

Pravno lice (koje i kako) / Host company (state who and how) / Socit hote (indiquer les nom et modalit)s
..............................................................................................................................................

29.

Novana sredstva za izdravanje

Means of support during your stay
Moyens de financement utiliss
au cours du sjour

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. Vai do
Travel and/or health insurance. Valid until
Assurance voyage et/ou assurance maladie. Valable jusqu`au:
...........................................................................................

30.

Datum dolaska

/ Date of arrival / Date darrive

31.

Datum odlaska

/ Date of departure / Date de dpart

32.

Nain putovanja

/ Means of transport / Moyens de transport

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

33.

Ime branog druga

34.

Prezime branog druga

35.

Prezime branog druga pri roenju

Spouses family name at birth
Nom de famille du conjoit la naissance

36.

Datum roenja branog druga

/ Spouses date of birth / Date de naissance du conjoint

37.

Mjesto roenja branog druga

/ Spouse place of birth / Lieu de naissance du conjoit

38.

Djeca
Children
Enfants

Ime i prezime
Name and first name
Nom - Prnom

/ Spouses first name / Nom de famillie du conjoit

/ Spouses family name / Nom de famille du conjoit

Datum roenja
Date of birth
Date de
naissance

1. .................................................................................................................................................................
2. .................................................................................................................................................................
3. .............................................................................................................................................................
39.

Pri punoj svijesti izjavljujem i pristajem na sljedee: svi moji lini podaci koji se navode
na ovom obrascu zahtjeva za vizu proslijedie se, ako je potrebno, na rjeavanje i provjeru
nadlenim organima Crne Gore, u cilju odluivanja o ovom zahtjevu.
Na moje izriito traenje, organ koji odluuje o mom zahtjevu obavijestie me o nainu, propisanom
crnogorskim zakonodavstvom, na koji mogu ostvariti pravo na provjeru svojih linih podataka, te njihovu
izmjenu ili brisanje, naroito ako bi bili netani.
Izjavljujem da su svi podaci koje sam naveo/la u ovom obrascu istiniti i tani. Svjestan sam da e bilo koja
lana izjava imati za posljedicu odbijanje mog zahtjeva ili ponitenje ve izdate vize.
Obavezujem se da u napustiti dravnu teritoriju Crne Gore po isteku roka vaenja vize, ako
mi viza bude izdata. Obavijeten sam da je viza samo jedan od uslova za ulazak na dravnu teritoriju
Crne Gore. Svi uslovi za ulazak ponovo e biti provjereni pri ulasku na dravnu teritoriju Crne Gore.
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 Montenegro 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 Montenegro 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 Montenegro.
The prerequisites for entry will be checked again on entry into Montenegro.
En connaissance de cause, jaccepte que les donnes caractre personnel me concernat qui figurent das le
prsent formulaire de demande de visa soient communiqes aux autorits comptentes du Montngro
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 vrifier les donnes caractre personnel me concernat et les faire modifier 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 du Montngro 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 du Montngro.
Toutes les conditions pralables seront vrifies de nouveau loccasion de lentre en territoire national
du Montngro.

40.

Adresa podnosioca zahtjeva

41.

Broj telefona podnosioca zahtjeva

42.

Datum i mjesto

43.

Potpis podnosioca 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)

/ Applicants home address / Domicile dorigine du demandeur

/ Telephone number / Numro de tlphone

/ Place and date / Lieu et date