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Application for National Visa

This application form is free

PL

1. Surname (Family name) (x)

WYŁĄCZNIE DO UŻYTKU

SŁUŻBOWEGO

OFFICIAL USE ONLY

2. Surname at birth (Former family name(s)) (x) Data złożenia wniosku: 3. First name(s) (Given name(s)) (x)

Numer wniosku:

4. Date of birth (year- month-day)

5. Place of birth

6. Country of birth

7. Current nationality

Nationality at birth, if different:

Wniosek w we ambasadzie wspólnym złożono: ośrodku lub konsulacie

u u przyjmowania usługodawcy pośredniczącego wniosków podmiotu

na komercyjnego granicy

Nazwa:

inne

8. Sex

Male Female

9. Marital status

Single Married Separated Divorced

Widow(er) Other (please specify)

10. In the case of minors: Surname, first name, address (if different from applicant’s) and nationality of parental authority/legal guardian

Wniosek przyjęty przez:

11. National identity number, where applicable Dokumenty dokument środki zaproszenie środek podróżne utrzymania transportu uzupełniające: ubezpieczenie podróży

inne: medyczne

Decyzja odmowa wydanie o wizie: wizy: wydania wizy

Termin ważności:

12. Type of travel document

Ordinary passport Diplomatic passport Service passport Official passport Special passport

Other travel document (please specify)

13. Number of travel document

14. Date of issue

15. Valid until

16. Issued by

17. Applicant’s home address and e-mail address

Telephone number(s)

18. Residence in a country other than the country of current nationality

No

Yes. Residence permit or equivalent No Valid until Od

Do

Liczba wjazdów:

1 2 wielokrotny

* 19. Current occupation

* 20. Employer and employer’s address and telephone number. For student, name and address of educational establishment.

21. Main purpose(s) of the journey:

Tourism Business Visiting family or friends Cultural Sports Official visit

Medical reason Study

Other (please specify)

Liczba dni:

22. Member State(s) of destination

POLAND

23. Member State of first entry

24. Number of entries requested

Single entry Two entries Multiple entries

25. Duration of the intended stay of transit

Indicate number of days

The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent ascendant) while exercising their right to free movement. Family members of EU, EEA or CH citizens shall present documents to prove this relationship and fill in fields No 34 and 35.

(x) Fields 1-3 shall be filled in in accordance with the data in the travel document. 26. Schengen or national visas issued during the past five years

No

Yes. Dates(s) of validity from to 27. Fingerprints collected previously for the purpose of applying for a Schengen visa

No Yes

Date, if known 28. Entry permit for the final country of destination, where applicable

NOT APPLICABLE 29. Intended date of arrival to the Republic of Poland 30. Intended date of departure from the the Republic of Poland

* 31. Surname and first name of the inviting person(s) in the the Republic of Poland. If not applicable, name of hotel(s) or temporary accommodation(s) in the the Republic of Poland. Address and e-mail address of inviting person(s)/hotel(s)/temporary accommodation(s)

Telephone and telefax

* 32. Name and address of inviting company/organisation Telephone and telefax of

company/organisation

Surname, first name, business address, business phone number, telefax, and business e-mail address of contact person in company/organization

* 33. Cost of travelling and living during the applicant’s stay is covered

by the applicant himself/herself

Means of support

Cash

Traveller‘s cheques

Credit card

Prepaid accommodation

Prepaid transport

Other (please specify)

by a sponsor (host, company, organisation), please specify

referred to in field 31 or 32

other (please specify)

Means of support

Cash

Accommodation provided

All expenses covered during the stay

Prepaid transport

Other (please specify)

34. Personal data of the family member who is an EU, EEA or CH citizen Surname

First name(s)

Date of birth

Nationality

Number of travel document of ID card

35. Famila relationship with an EU, EEA or CH citizen

spouse child grandchild dependent ascendant 36. Place and date

37. Signature (for minors, signature of parental

authority/legal guardian)

I am aware that the visa fee is not refunded if the visa is refused. Applicable in case a multiple entry national visa is applied for (cf. Field No 24): I am aware of the need to have an adequate travel health insurance in the meaning of regulations on health care benefits financed out of public funds or travel health insurance for my first stay and any subsequent visits to the territory of the Republic of Poland. I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that lodging an application or providing documents containing false personal data or false information, as well as declaring untruth, concealing the truth, falsifying, counterfeiting, or forging a document in order to use it as authentic or using it as authentic in a national visa procedure will lead to refusing the national visa or annulling an issued national visa. I am also aware that under Polish law, such conduct amounts to an offence that can be punished by fine, restriction on liberty or imprisonment.

I undertake to leave the territory of the Republic of Poland at the latest on the last day of the period of my stay authorized by the national visa. I am aware that possession of a national visa is only one of the conditions to enter the territory of the Republic of Poland. The mere fact that a national visa has been granted to me does not mean that I will be entitled to compensation if I fail to meet the entry conditions set forth in the Act on Foreigners and I am therefore refused entry into the territory of the Republic of Poland. The entry conditions will be verified again on arrival in the territory of the Republic of Poland.

I am aware that the issued national visa may be revoked if I no longer meet the conditions for issuing it. When filing the application for a national visa for the purposes of undertaking or continuing full-time first or second cycle degree programme, uniform Master’s degree studies, or for the purposes of undertaking PhD studies, carrying out research or development work, undergoing an internship or joining the European Voluntary Service, if you failed to submit all documents necessary to verify the details included in the application and the grounds for filing the visa application, you have the right to submit them within fourteen days of filing the application. Place and date

Signature (for minors, signature of parental authority/legal guardian):

1

In so far as the VIS is operational.

Contact this candidate