Ambasciata @'talia a Beirut, meas erry APPLICATION FORM / FORMULARIO e [National Vea Appliation (D)/ Domanda di visto mazionale (2) ‘This application form is free / Modulo gratuito FOTOGRAFIA PHOTO (COMPLETE THIS FORM IN ALL ITS ENTIRETY. FAILING TO DO SO MAY RESULT IN LONGER PROCESSING TIMES ‘SI PREGA DI COMPILARE IL PRESENTE FORMULARIO IN TUTTE LE SUE PARTI UNA COMPILAZIONE INCOMPLETA POTREBBE COMPORTARE UN ALLUNGAMENTO NEI TEMPI DI TRATTAZIONE, 1. Surname (amily meme) /Cogrome (3) 2 Surname at birth (Former family sme (6)/ Cognome alla nascita [eognomek precedente) () ‘3. First name (=) (Given name ()/Nome & (3) 4. Date firth (aymontheary/ |S. Place oftirth/Luogo di nascita | 7. Carrent nationality / Caden ‘Data di nascta (gginmiaa) aul 6. County ot birth) Stato di nascita | Nationality at birt, if different Ctadnaet alle nec, 2ediverne couanualcbatas Marital Statue / tele 1D Male OO Female Single Distt itera Married sCoigato Cl Separed Soper Leruneificienzen! 1 Divoreed Dvoraino CI Widom(er)! Yew f) 10. In the cae of minors: surname, first mame, address (if different from applicants) and nationality ofthe holder ‘of parental responsibilty legal guardian! Per minot = cognome, nome, indirizo (se diverso da quello del ‘riehiedente)ectadinanza del ttolare della potest gentorini-ndoreIgale Ti, Type of eravel document Tipo d documento 1D Ordinary Passport Parsaporto ondmario C) Diplomatic passport | Passapori diplomatico Service passport /Passaporo dl servicio) Oficial pasport | Passaporto wficiale i Special passport / Passaporto Speciale (2 Other travel docement (plese rect) / Document vag dali frecare) 12 Namba otra 15.Date ofisue/ Daas | 14, Valid unt/ Yauco | 15.Tsued by / arias occa et aoc foal ae 16, Applicant's home address and e-mall address “Telephone number(s) Indvizso di residencaldomicloeindirzzo di posta cletronica del richiodents | Numortlefona/ 17. Rovdene in country ter than he country of arent atoll Raia iu pave dre del pase dada ata Norn 1 ver/St Residence permit or equivalent / rite sogsiemeoequvalene Now. ‘Valid until 1 Yalido fin a. 18, Current occupation / Occupacione ttle 19, Employer and employer's address and telephone number. For students, name and address of educational establishment /Datore dl nore eral indir emimere ditlfona Per glide nome cinco dll tnt drone () as speed nthe teavel document com ndct nel documento aga ‘Spaziorservato all'amuministrazione For afi we ony Data della omanda alo sportell/ Date of pecan [Numero della mands di visto Poss applstion mater Domanda presentata presso Application ede 1D Ambaseiata/Consolato EnbaropConalte Fornitore i servis Service Provider [Responsable della patie’ ie aoe "Nome dl chi ha ricevuto la ratica allo sportello/ Nae of he ern who dea with he flea te 1 Document diag e (Mens snitenen eof tate tien 1 Meza a trasportoean Aesearasone sntaria dt neo Dates er Decisione relativa al visto be 1D utatate ied taint amet “Tipo a visto / Np af ia 81am i er ingen) amr ari D1 02 C statptnsite [Numer gloat oft20, Main purposes) ofthe journey /Scopol principle del sogsiono: Cr Jotning family member! Accompanying family member! icnangimeioFanire/Fanare ol seit 1 Religious reasons Moc religiasi (C1 Sport / sport] Mission) fasione Cl Diplomatic Diplonsico C1 Medical reasons /Cure ediche C1 Study / Studio Cl Adoption /4dorone C Salaried employment / Lavore nborainato 1 Setfempleyment/ lavoro autonome Cl Other (plese pei) / Dials (precise) 21, Your destination tn Italy Desanoe Hain 22 Schngen State of st entey i appebl)/ Evernale Sao Sohenzen primo ingress 23. Namberofentes requested Maer d nr richest 1D Sing entry / Uno 1D Two entries Due 1D stp entries / Mutt 24, Duration of stay / Specify the number of days (max 365)/ rata del veggoreo del rasa previ Indare tl mmere dt orm 365) 25. Intended date of arrival inthe Schengen area Dasa poten previ dl area Schengen 26, Detailsaf the Host entity in Italy (person/body/authorityinstitution/company) Deitagi del ooptants in ala (persona/onelatontaistncionehocietd) ‘Address and e-mail addres ofthe host entity Indian pote letra del oti Talore ‘Telephone and tlefax of the host entity or ofthe employer fae dll optane 9 del dtr dle 217 Name and address ofthe host entity ‘Nome e india del xptante ‘Telephone and tolfax ofthe host entity Telefon «fx dell ospitanie ‘Surname, fest same, addres, telephone, Wefas, and ema address of contact person i of te host etl J Cograme nome, iniriso, telefono, fare indiizo di potaelatronica del referent presto ent oxptante 28, Cos of travelling and living during the applicants stay is covered / Lespese digs edsogstoro del riehedete soo acarc by the applicant himseltherstt/ del richedente stesso | C) by a sponsor (hos, company, organisation) - please specify el promoare(ospt,societ,organizazion)-precisare ‘Means of support / Mezz di sussstenza cash Contant Cl Traveller's chequesTraveter's ches 1 ret nr Carta dt eredito repaid accommodation Alloggio prepagato 1 repaid ranpert/Thasporto prepagato otter pease spe) Aliro (precsare) ‘THIS INFORMATION IS NOT NECESSARY FOR ‘THE FOLLOWING TYPES OF VISA: amily reunion, Accompanying Family member, Salaried or self employment, Diplamatie, Adoption INDICAZIONE NON NECESSARIA NEI_CASO DI VISTO PRR’ Ricongiungimento Familiar, Familie al Seguito, Lavoro Subordnato/Autonomo, Diplomatic, Adozione. referred to in fild dc alle catlle30orlo 31 11 omer «please specify / lio (precisare) Means of support / Mezzi di sussistenza 1D cases Conant Accommodation provides Alloggio D Amespenses covered during the stay Tate le spevecoperte duran il sogglomo rept ransport | Trasport prepagato other (pease speci) Atro (recsare) REMARKS / OSSERVAZIONIE ANNOTAZIONS29, Person deta ofthe fly member wha in EU, EEA or CH izes / Dat anagrafc del fniliarecittadino UB, SEB. CH ‘Surname Cognome ‘ir ame) /Name() ‘Die otis Data Bi nascir ‘Rana Citadinansa "Naraber of travel document or ID Card Numero del documento di viegso o della carta dents 30, Yamyeeeteniip wih en EU, EEA or CH eiaen/Vincoofamilore con wn citadino UE, SEE @ CH i speute Coniuge C1 cata Figo C Grandchit! Nipte (4 nomoa) 1 Dependent ascendant ( Ascendente a carico 1 oeer (pease spect) Air (preisare) 31. Place and date /Euogo ¢ data 32, Signature (for minors, signature of holder of parental authority / legal guardian) rms per minor fra del lar del poet genoa ‘irate am aware that the visa fees not refunded if the visa i refused /Sono a conoscenza del fato che tl fia del visto non di lung al rimborsa della ass composi INFORMATION ON THE PROCESSING OF PERSONAL DATA /INFORMATIVA SUL TRATTAMENTO DEI DATI PERSONALL The collection of the data provided inthis application form, the taking of your photograph and, if applicable, the taking of your fingerprints, are [compulsory for the examination ofthe visa application. Any personal data concerning you contained inthe visa application form, at Well as Your fingerprints and your photograph, shall be supplied to the relevant authorities of Italy and processed by those authorities, forthe purposes of 4 decision on your visa application. La raccolta det da richiest in questo modula e I sua fotografie, se del cata, la rlevazione delle sue impront digital sono obbigatorie pr Vesame della domanda di visto ei sui dat anagrafci che iguran nel presente modulo di domanda di isto, casi come le sue impronte Aigal ela sua forografa,saramo comunicat ale autora competent taliane trata dalle ses, a ink defadorione dna decsione i merito alla sa idomande ‘Such daa, 2s well as the data concerning the deelsion made on your application ora decision whether to cancs, revoke or extend a via issued, shall be ‘entered into, and stored in the IT system ofthe Consular Diplomatic Representation and ofthe Ministry of Foreign Affairs and International (Cooperation. Such data shall be accessible to the National Vien authorities. Furthermore, they shall be accesible tothe visa authorities and the futhrities competent fr carrying out check on ves at external orders and within the Member Ste, immigration and asylum authorities in the “Member Stats forthe parposes of verifying whether the conditions fe the legal entry int, stay and residence inthe feriory of the Member Sates are Tulle, of identifying persons whe do ot or who ne longer full there conditions. Under certain conditions the data shall also be available tothe designated authorities ofthe Member States and to Europol forthe purpose of the Prevention, detection and investigation of terrorist offences and of other serious criminal offences Tali dat cos come dat riguardand la decisione relative ala sua domanda ouneventualedecsine di amallamentoo revoea di un visto rilasciato, saranno inert «conserva nel stoma informatica della Rappresentana diplomatic consolare del Ministero deli Afri Ester e della Cooperazione Inernasionale. Tat dat sarannoacceasibil lle torts azionali competent per vist. Inoltr,saranno accessible exdorta Schengen competent afm del control su vst allefrontore ester, alle autorii ‘legh Stati membri competent in materia dl immgrasione (i fin della verfce dsl? adempimento delle condiion di ingrenso,soggornae residanca regolar nel ‘errtrio degl Stati membriedelldentfcacione delle persone che non soddsfano,o nor soddlifano pi, qustt condicion). A determinate condcon, dat saranno anche accesible autora designate degl Stal membri ea Europol fir delaprevension,delndviduacione e ellinvestigaione di reat di erorisma e alr rea gravi The Ministry of Foreign Affairs and International Cooperation (Piazzale della Farnesina 1, 0013S Roma, www esterLit,dgit@esterL1 sth Iallan authority responsible (controller for data procesing I! Ministero degl Affari Exerc della Cooperacione internavinale(Pazzale della Farnesina I, 00135 Roma, ww.ester.t)&autorté italiana responsable (alae) de attamento de dat You have the right to obtain notifieation of the data relating to you recorded in the IT system and to request that data relating t you which are inaccurate be corrected and that data relating to you processed unlawfully be deleted For information Om the exercise of your right to check your Personal data and have them corrected or deleted, a3 well as on legal remedies according tothe national law of the State concerned, se and hitps/vstopertallaeterLit. B'suodirizo ottenere la comunicazione del dat relat alla sua persona relsrat nel ststema informatio e chedere che dri nest elativala sua persona vengano retical eche quel relat alla sua persona tata ectamente vengano cancellan.Perinformaztons sul serio del suo dirt a verficaretsuoi dat anagrafc ea etfeart osopprimerl, csi come elle te i ricorso previ a tale riguardo dalla Tegislaionenazionale dello Stato ineressao, ved wav.esteri.it« hp hisopertaliasier. it Further information shall be provided by the authority examining your application upon request. The Italian national supervisory authority competent forthe protection of personal daa is the Garance per la Proteslone del Dal Personal italian Authority for Data Protection) (Piazza di /Montecitorio 121, 00186 Roma, www garanteprivacyit; tel: +3906 636771). Ulerion informacion saranno fore su sua richesta doll ator che esamina la sua manda Luton dl controla nazionalewtalianacompetete ix materia dh taela de dat personal 1! Garate per la Protezione dei Dati Personal (Piazza di Montectoro 121, 00186 Roma, www garaneprivac' i) declare that to thebestof my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements hall result in ay pplication being rejected or ina visa already granted to me being revoked and may also render me able to prosecution under te aw of the Diplomatic or Consular Mission (Article 331 ep) Dichavo che ut dat da me ornit sono complet ed vat, Sono consapevole ce le dicharaciont [false comporteranno i respingimento della mia domandao Vannuliamento del visto gid concesso comporerana la richest di avo di axon! gudisarie a parte dela Rappresentanca ai sensi della leisacione dello Stato (articolo 331 ep) The mere fact that a visa as been granted to me docs not mean that I wil be ented to compensation if I fail to comply with the relevant provisions of Article 5() of Regulation (EU) No $62/2006 (Schengen Borders Code) and of Article 4 Legislative Decree 26898 and Tam therefore refesed entry. La mera cancersione de visto non di drt adalcun tipo di risarcimento gualora lo non sodas le condition! previ dalfartola 3, paragra | cel Regolamento (UE) n. 5622006 (Codie Frontiere Schengen) e dell'artcolo 4 del D gs. 28898 per tal motvi mi venga fat ingrese, 33, Place and date /Luogoe data 34, Signature (for minors, signature of holder of parental authority! legal guardian) ‘Firma (per minor, frma del ttolare della potest genitoriale tore lgaley