Operator de date cu caracter personal notificat sub nunnarul S2gs

FOTOGRAFIE

STAMPILA CONSULATULUI GENERAL AL ROMANIEI LA

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VESiKALIK FOTOGRAF
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Solieitare de VizS Application for Visa Vize Bagvuru Forrnu

TIP DE VIZAI TVPE OF V|SA I V1ZE TUNU:
Formular gratuit / This application form is free

A, B, C

/ Bu form rjcretsizdir

1. Numele / Surname(s) (family name(s)) / Soyadl: FOR EMBASSY

2. Numele la nagtere/ Surname(s) at birth (earlier family name(s)) krzfuk soyadr: 3. Prenume

/ dnceki soyadl veya

CONSULATE USE ONLY/ KONSOLOSLUK

TARAFINDAN

DOLDURULACAK Data solicitirii

:

/ First narnes (given names)

,/

Adr:

4, Data nagterii / Date of birth (day-month-year) Do$um tarihi (gtin-ay-yrl): 6. Locul gi tara nagterii
7. Cet-lenia

5. CNP

/ lD-number

Vatandaglrk sicil numarasr:

Document procesat de
Documente doveditoare:

Place and country of birth

/ Dolum yeri ve iilkesi:

prezenti / Current natiohality(ies) / Tabiyeti:

8. Cetilenia la nagtere /.Original nationality (natidnality at birth) / llk tabiyeti:

'10.

I
X

PaEaport valabil

Mijloace financiare

9. Sexul / Sex

/ Cinsiyet:

Statut civil / Marital status / Medeni hali:

n lnvitaJie n Mljloace de
transport

I I

Bdrbdtesc / Male / Erkek

Femeiesc

I
n

Celibatar / Single

BekAr

/ Female / Kadrn

C5setorit / Married / Evli Separat / Separated / Ayrrlmrg

n Bilet de calatorie [l Asigurare de

I
tr
tr

sdndtate Dovada asigurarii

Divo(at / Divorced / Boganmlg Vdduv(d)/ Widow(er)/ Dul

conditiilor de cazare

E Altele / Other / Diler

1

1. Numele

tati

lui

Baba adr:

/ Father's name /

12. Numele mamei

/ Mother's name / Anne

adr:

Exceptii: (se va completa in functie de documentele prezentate de solicitant, in conformitate cu art.40 din

o.u.G.194/20n2)]

13. Document de c5!Etorie / Type of passport

Fasaport tilri.i:

f
tr

Pagaport diplomatic Pagaport turistic

/ Diplomatic

passport

I Diplomatik pasaportu

/ National passport / Turistik pasaportu / Cahgma pasaportu

(1

I
tr

Pagaport de serviciu / Service passport

Document de cdldtorie pentru refugiati tTraveldocument seyahat belgesi

9s1 conv.) / Multeci

I I
tr

Pagaport pentru strdini / Alien's passport / Yabancllar pasaportu Carnet de marinar I Seaman's passport

/ Gemici pasaportu / Diger(belirtiniz):

Altele (specificati) / other travel document (please specify)

14. Nr. de pagapod

/ Number of passport Fasaport Numarasl:

15. Emis de

/ lssued

by / Veren makam

16. Data emiterii

/ Date of issue {daymonth-year) / Verilig tarihi (gtin-ay-yrl)

17. Valabil
:

p6ni la / Valid until (day-month -yearl / Gegerlilik tarihi (grin-ay-yrl) :

18. Dacr aveti domiciliul

reintoarceti in acest stat / lf you reside in a country other than your country of origin, have you permission to return to that country? / Bagka iilkede ikdmet ediyorsanrz o rilkeye dcjnmeniz miisaade ediliyor rnu?

in alt stat dec6t cel de origine, vi este permis sr vi

f
n

Nu

No

Hayrr

Da (numdrul gi valabilitatea permisiunii) / yes, (number and validity) s[iresi):

/ Evet (sayrsr ve

"19. Functia ocupatd in present / current occupation

/ Mevcut gcireviniz:
Viza:

*20. Angajatorul, adresa acestuia gi nr. de tel. pentru elevi gi studenli, denumirea gi adresa institutiei de invrtSmant / Employer and employer's addresj and telephonl

f I

Refuzatd Acordatd

telefonu. dlrenciler iqin okulun adl ve adresi:

number. For students, name and address of school.

ig verenin adr, adresi ve

Tipul de 21. Destinatia principald Main destination,/ Esas gidece!iniz yer

vizi

/
:

22. Tipul de vizd / Type of Visa Vize tfirii :

23. VizdlVisa Nize

Tranzit aeroportuar / Airport transit / Hava alanr transit Tranzit / Transit / Transit

I
n

lndividuald

/
/

lndividual/ Ferdi
Colectivd / Collective

nc
Nr. de intriri:

NA NB

I I

Toplu

Scuria sedere / Short stay

Krsa sr.ireli

I1 n2 trMuttiple

24. Nr. de intrlri solicitate / No. of entries requested

25, Durata gederii

siiresi:

/ Duration of stay / Kalma

/ istenilen

Valabild de la

lstenilen girig saysl:

f
E

Unici intrare / Single entry / Tek girig

Doud intrS,ri /Two entries

Viza solicitatd pt. / Visa is requested for

vize:

/ iki giriq

..... zile / days / g0n igindir.

La;

Vuttiple intrdri /Multiple entries

Qoklu girig

siireleri:

26' AIte vize emise in ultimii 3 ani gi valabiiitatea lor / Other visas (issued during the past three years) and their period of validity / Son 3 yrlda aldl{rnrz bagka vizeler ve

var mr?

27' ln cazul unei vize de tranzit, detineti permisiunea de a cilStori in statul de clestinalie?/ ln the case of transit, have you an entry perrnit for the final country of destination? / Transit durumunda esas gitmek istedi!iniz tilkeye seyahat etme iznlniz
Nu

No

/ Hayrr f, Da, valabild

Emisd de

pAnd la / yes, valid until

/ Evet ve: ......

tarihine kadar gegerlidir.

lssuing authority / Veren makam : .......

9eoerl anrerloare ln Homania sau lh alte state SchenEen / Previous stays in Romania or other schengen states / Romanya'ya <lnceki gidigleriniz veya bagka Schengen iilkeleri:

''2.t.

29. Scopul gederii in Romdnia

/ purpose

of travel

,/

Seyahat amact:
Afaceri (C/A)/ Business

I !
n
Transport (ctTR) / Transportation /

iq

Nakliyat I

Turism (c/TU) / Tourism / Turizm

FOR EMBASSY / CONSULATE USE ONLY / BU KISIM SADECE KONSOLOSLUK

Vizitd (cN\t) / Visit to Family or Friends / Akraba veya dost ziyareti

ieiNDiR

activities in accordance whith romanian law / Romanya yasalanna aykrrr olmayan krsa sLireli kultur, bilimsel, insani ve trbbi tedaviler.

nctivitdti culturale, gtiintifice, umanitare, tratament medical de scurta durata care nu contravin legilor romAne (C/ZA),/ Shortcultural, scientific, humanitary, medical treatment

Activitati sportive (C/SP) / Sport / Spor faaliyefleri

*30. Data sosirii

/ Date of arrival (daymonth-year) / Girig tarihi (g0n-ay-yrl):

n31. Data plec5rii

/ Date of departure (daymonth-year) I erkrg tarihi (gfin-ay_yrl):

*32. Punctul de intrare, sau traseul de transit / Border of first entry or transit route / Girig kaprst ya da transit yolu:

*33. Mijloc de transport / Ulagrrn aracr:

/ Means of transport

*34. Denumirea firmei romAne de contact gi a pensoanei responsabile ?n cadrul acesteia. in absentd, denumirea hotelult.ri sau adresa ternporari ?n Romdnia / Name of host or company in Romania and contact person in host company. lf not applicable, give name of hotel or temporary address in Romania. / Flomanya'daki irtibat girketiirin adr ve yetkilisinin adr. Yoklu$unda, kalaoa!rnrz oteiin adr veya gegici olarak
kalaca$rnrz adres:
Nume/Name/Adi:

'
/ Full address /

Tel. gi fax

/ Phone and fax

no. / Tel. ve faks

Adresa completd
AErk adresi:

e-mail / e-mail address / e-posta adresi:

*35. Cine suportd cheltuielitre de deplasare gi de gedere in Rorndnia / Who is paying for your cost of travelling and for your costs of living during your stay?? / Flomanya'ya gidiq ve kahq masraflarrnr kim kargrhyor?

Subsemnatul

Myseif

/ Kendim
kigisi

E Persoani fizicd romdnd / Host person(s) / Romanya ozel

E Persoani juridicd romdnd (numiJi

cine qi anexati documente doveditoare) / Host company. (State who and how and present corresponding documentation) Romanya tuzel klgisi (adrnr belirtiniz ve ilgili belgeleri ekleyiniz):

*36. Modalitdti de intretinere in Romdnia Romanya'da gegim gekilleri:

/ Means of support during your stay /

I f
l)

Cash / Nakit

para tr

Cecuri de cdldtorie / Travellers' cheques / Seyahat qekleri

Ce{i de credit / Credit cards

Kredi karilarr

Cazare pldtitd / Accommodation Alteie / Other

/ 0nceden

odenmig konaklama

I I

DiQer (belirtin):

Asigurare medicalS valabild pdni la / Travel and/or health insurance. Valid until: .............tarihine kadar geqerli sa!hk sigortasr

37. Numele sotului {soliei) / Spouse's family name Eginizin soyadr:

38. illurnele la nagtere al sotului (sotiei) Spouse's family name at birth / Eginizin ilk soyadr {krzhk soyadr):

39. Prenumele sotului {sotiei) ,/ Spouse's first name / Eginizin adr:

4O.Data de nagtere a sotului {sotiei) / Spouie's Oate it Oirttr

(day-month-year) / Eginizin do!um tarihi (giin-ay,yrl)

41. Locul de nagtere al sotului (sotiei) / Spouse,s place of birth / Eginizin

do!um yeri:

42. Copii (se vor completa solicit5ri separate pentru cei care detin pagaport individual)

Children (Applications must be submitted separately for each passport)

{kendi adrna pasaportu olanlar igin ayrr bagvuru formu doldurulur):

Qocuklar

Nume
1

/ Name / Soyadt Prenume / First name / Adt Data nagterii / Date of birth / Dogum tarihi

43. Datele personale ale cetSleanului rom6n in intretinerea ciruia

completat doar de c5tre cei aflali in intrelnerea unui cetilean roman

vi gisifi.

data of the Romanian citizen you depend on. This question shpuld bejrnswered only by family members of Romanian citizens. / Size bakmakla ytikiimlii Romanya vatandagrnrn gahsi doldurulur.

Rubric6 de Personal

bilgileri. Bu hane sadece bir Romanya vatandaStnln bakrmrnda olanlar tarafrndan

Nume/Name/Soyadt:

Prenume

/ First Name / Adr:

Nr. de pagaport / Number of passport,/

Data nagterii

/ Date of Birth / Do[um tarihi:

Pasaport Numarasr:
Legdtura familiald

Family relationship / Akrabalrk ba$r:

44. Daca aveti alte rude in Romania? / lf you have any relatives in Romania? Romanya'da bagka akrabalanntz var mr?:

45. Am luat la cunogtintd urmdtoarele: toate datele personale cu privire la subsemnatul(a) care apar in prezentul formular vor fi puse la dispoziiia autoritd! ilor romdne competente gi procesate de cltre acestea, dupd caz, in scopul ludrii unei decizii cu privire la prezenta

solicitare de vizd. Aceste date pot fi introduse qi stocaie in bazele de date accesibile
autoritdJilor romane competente.

de a verifica datele personale furnizate, de a dispune modificarea sau indep5rtarea lor, dacd

Urmare solicitdrii exprese a subsemnatului, autoritdfile consulare menite sd proceseze prezenta solicitare md vor informa cu privire la la modalitatea in care imi pot exercita dreptul

se dovedesc incorecte, in conformitate cu prevederile legislatiei in vigoare in Romdnia.

Declar
Decldr

prezentei solicitdri sau la anularea vizei emise in baza acestora gi pot duce la declangarea
Rom6niei la expirarea vizei ce mi-a fost acordatS.

ci, dupd gtiinla mea, toate datele furnizate sunt corecte gi complete. ci am cunogtintd de faptul cd orice date false furnizate conduc la respingerea

urmiririi mele penale in conformitate cu legea rom6nd. Md oblig sd pdrdsesc teriioriul

pentru intrarea in Romdnia. simpla eliberare a vizei nu presupune'faptul cd sun.t indreptifit(d) la primirea unor.compensa.tii dacd nu indeplinesc condifiile prevdzute la c^"Fjlg\^"] ll. (Dispozilii generale privind intrarea, gederea gi iegirea str6inilor) al OUG 194/2002 9i imi este re'fuzai\, intrarea in Romdnia. indeplinirea condiliilor de inirare va fi supusd verificdrii la momentul intrdrii pe teritoriul Romdniei.//
Sunt de acord cu prelucrarea datelor prezentate in conformitate cu Legea 67712001
I am aware of and consent to the following: any personal data concerning me which appear

Am fost informat cd detinerea vizei nu reprezintd decAt una dintre condiliile de indeplinit

on this visa application form will be supptieO to the relevant authoritiels in Romanii'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 io 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 annulmeni 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 {act 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 ll (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 date presented in according with Law No. 67712001

verilece{i ve duruma gare vize bagvurusu konusunda bir karar altnmak Uzere igleme
konulacagr konusunda bilgilendirildim. Bu bilgiler ilgili Romen makamianntn ulaqabilece$i bilgi argivine aktartlt p muhafaza edilebilir.

igbu form iqinde yer alan ve kendime ait olan tum qahsi bilgiler Romanya ilgili makamlartna

Ozel istegim trzerine igbu bagvuruyu iqlemekle gorevli konsolosluk makamlart verdi$im qahsi bilgilerin kontrol edebilme, yanhq olduklarr taktirde onlarr de$igtirme veya silme hakktmr yuritrlukte olan Romanya yasalarrn hukLlmleri gere!ince nastl kullanabilece$imi bilgilendirir. iEbu formda yer alan tUm bilgiler bildidim kadarryla do$ru ve eksiksiz olarak verildi$ini beyan ederim, Verilen herhangi sahte bilgi bagvurunun reddedilmesine veya bu bilgilere dayanrlarak verilen vizenin iptaline vesile olup Romanya yasalartna gore cezai takip baglattlabilece!inden bilgim oldugunu beyan ederim" Verilen vizenin bitiminde Romanya'dan gtkaca$tmt taahhijt ederirn.

Vizenin verilmesl Romanya'ya girig gartlartndan sadece birini tegkil ettiIi konusunda bilgilendirildim. 194/2002 Sayrlr tarihli Romanya Hijktlmet Kararnamesi'nin ll. Bolumunde (Yabancllarrn girigi, kalmasr ve qrkmast hakktnda genel htikumler) yer alan gartlart yerine getirmedi!imden ulkeye girigim kabul edilmezse, sadece vizenin verilmesi tazminat isteme hakkr vermez. Girig gartlarrn yerine getirilip getirilmedi{i Romanya'ya giriq yaptldtQr zaman
denetlenir. 677/2001 sayrlr yasa gere!ince verilen bilgilerin iglenmesini kabul ediyorum 46. Adresa de domiciliu a solicitantului

/ Applicant's home

address / Bagvurantn ikdmet adresi

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

/ Place and date (day-month-year) / Bagvurunun yeri ve tarihi (giin-ay-yrl):

48. Datd la {locul gi data)

49. Semn5tura (pentru minori, semnStura reprezentantului legal) / Signature (for minors, signature of custodian /guardianl imza (regit olmayanlan igin yasal vekili);

Rubricile insotite de semnul *, nu trebuie completate de membrii familiei resortisantilor UE sau SEE (sot, sotie, copil sau ascendant dependent). Membrii familiei resortisantilor UE sau SEE trebuie sa prezinte documentele care dovedesc relatia de rudenie. The question marked with *, do not have to be answered by family members of EU or EEA citizens (spouse, child or dependent ascendant). Family members of UE or EEA citizens have to present documents to prove this relationship. (* )Yrldtzlt igaretli haneler AB veya SEE vatandaglanntn aile i.iyelerinin (eg, gocuk veya bakmakla yiikiimlii oldulu anne,baba) tarafrndan doldurulmayacakttr.

AB veya SEE vatandaglartntn aile 0yeleri akraballk badltltlr ispattytcr belgeleri ibraz etmeleri gerekmektedir.