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For official use only 签证机关专用 Date of application: Visa application number: 1. Surname (Family name) (x) 姓 2. Surname at birth (Former family name (s) (x) 出生时姓氏 3. First name (s) (Given name (s) (x) 名 4. Date of birth (day-month-year) 出生日期 (日-月-年) 5. Place of birth / 出生地 6. Country of birth / 出生国 9. Marital status / 婚姻状况 Single / 未婚 Married / 已婚 Separated / 分居 Divorced / 离异 Widow (er) / 丧偶 Other / 其它 ……………………………. 10. In the case of minors: Surname, first name, address (if different from applicant’s) and nationality of parental authority / legal guardian / 未成年申请人 须填上合法监护人的姓名、住址(如与申请人不同) 、及国籍 11. National identity number, where applicable 身份证号码，如适用 12. Type of travel document 护照种类： Ordinary passport / 普通护照 Diplomatic passport / 外交护照 Service passport / 公务护照 Official passport / 因公护照 Special passport / 特殊护照 Other (please specify) / 其它旅行证件（请注明）：…………………………………… 13. Number of travel 14. Date of issue 签发日期 15. Valid until 有效期至 16. Issued by 签发机关 document 旅行证件编号 Telephone number(s) 17. Applicant’s home address and e-mail address 申请人住址及电子邮件 电话号码 18. Residence in a country other than the country of current nationality 是否居住在现时国籍以外的国家 No 否 Yes. Residence permit or equivalent …………………… No ………………… Valid until..………………………….. 是。 居留证 编号 有效期至 *19. Current occupation 现职业 *20. Employer and employer’s address and telephone number. For students, name and address of educational establishment. 工作单位名称，地址和电话，学生填写学校名称及地址 7. Current nationality / 现国籍 Nationality at birth, if different: 出生时国籍，如与现国籍不同 Application lodged at Embassy/Consulate CAC Service provider Commercial intermediary Border Name: Other File handled by: Supporting documents: Travel document Means of subsistence Invitation Means of transport TMI Other: 8. Sex / 性别 Male / 男 Female / 女 Visa decision: Refused Issued A C LTV Valid From ……………………… Until ……………………… Number of entries: 1 2 Multiples Number of days: 21. Main purpose(s) of the journey: 旅程主要目的 Tourism / 旅游 Business / 商务 Visiting Family or Friends / 探亲访友 Cultural / 文化 Sports / 体育 Official visit / 官方访问 Medical reasons / 医疗 Study / 学习 Transit / 过境 Airport transit / 机场过境 Other (please specify) / 其它 (请注明）
(x) Fields 1-3 shall be filled in accordance with the data in the travel document 字段1-3 须依据旅行证件填上相关资料 22. Member State (s) of destination / 申根目的地 23. Member State of first entry / 首入申根国 24. Number of entries requested 申请入境次数 Single entry / 一次 Multiple entries / 多次 Two entries / 两次 25. Duration of the intended stay or transit Indicate number of days 预计逗留或过境日数
The fields marked with * shall not be filled 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.
欧盟、欧洲经济区或瑞士公民的家庭成员(配偶、子女或赡养的老人)行使其自由往来的权利，不必回答带（*）号的问题。欧盟、欧洲经济区或瑞士公民的家庭成员必须填写第34条及35条的问题并提交证明其亲属关系的文件。 26. Schengen visas issued during the past three years / 过去三年获批的申根签证 No / 没有 Yes. Date (s) of validity from ………………………………………. to ………………………………………….. 有。 有效期由 至 27. Fingerprints collected previously for the purpose of applying for a Schengen visa 以往申请申根签证是否有指纹纪录 No / 没有 Yes 有 …………………Date, if known / 如有，请写明日期………………. 28. Entry permit for the final country of destination, where applicable 最后目的地之入境许可 Issued by ………………….……...…………… Valid from ……………………………until ……………………………… 签发机关 有效期由 至 29. Intended date of arrival in the Schengen area 预定入境申根国日期 30. Intended date of departure from the Schengen area 预定离开申根国日期 *31. Surname and first name of the inviting person (s) in the Member State (s). If not applicable, name of hotel (s) or temporary accommodation (s) in the Member States (s) 申根国的邀请人姓名。如无邀请人， 请填写申根国的酒店或暂住居所名称 Address and e-mail address of inviting person (s) / hotel (s) / temporary Telephone and telefax 电话 及 传真号码 accommodation (s) 邀请人/酒店/暂住居所的地址及电字邮件 *32. Name and address of inviting company / organization Telephone and telefax of company / 邀请公司或机构名称及地址 organisation 邀请方电话及传真号码 Surname, first name, address, telephone, telefax, and e-mail address of contact person in company / organisation 邀请公司/机构的联系人姓名、地址、电话、传真及电子邮件 *33. Cost of traveling and living during the applicant’s stay is covered 旅费以及在国外停留期间的生活费用 by the applicant himself/herself / 由申请人支付 Means of support / 支付方式 Cash / 现金 Traveller’s cheques / 旅行支票 Credit card / 信用卡 Prepaid accommodation / 预缴住宿 Prepaid transport / 预缴交通 Other (please specify) / 其它(请注明) by a sponsor (host, company, organisation), please Specify / 由赞助人（邀请人、公司或机构）支付，请注明 referred to in field 31 or 32 / 参照字段31及32 other (please specify) / 其它 (请注明) Means of support / 支付方式 Cash / 现金 Accommodation provided / 提供住宿 All expenses covered during the stay / 支付旅程期间 所有开支 Prepaid transport / 预缴交通 Other (please specify) / 其它(请注明)
34. Personal data of the family member who is an EU, EEA or CH citizen 家庭成员为欧盟、欧洲经济区或瑞士公民，请填写其个人信息 Surname 姓 Date of birth / 出生日期 Nationality / 国籍 First name(s) 名 Number of travel document or ID card 旅行证件或身分证编号 35. Family relationship with an EU, EEA or CH citizen 申请人与欧盟、欧洲经济区或瑞士公民的关系 spouse child …….………………………. grandchild dependent ascendant 配偶 子女 孙儿女 受养人 36. Place and date / 地区 及 日期 37. Signature (for minors, signature of parental authority/legal guardian) 签字（未成年人由其监护人代签） I am aware that the visa fee is not refunded if the visa is refused / 本人知道即使签证被拒也不能退还签证费 Applicable in case a multiple-entry visa is applied for (cf. field No24): / 适用于申请多次入境签证 (参照字段24) I am aware of the need to have an adequate travel medical insurance for my first stay and any subsequent visits to the territory of Member Status. 本人知道须预备有足够保额的旅游医疗保险作为首次及其后各次出发到申根国家领域之用 I am aware of and consent to the following: the collection of the data required by this application form and the taking of my photograph and, if applicable, the taking of fingerprints, are mandatory for the examination of the visa application; and any personal data concerning me which appear on the visa application form, as well as my fingerprints and my photograph will be supplied to the relevant authorities of the Member States and processed by those authorities, for the purposes of a decision on my visa application. Such data as well as data concerning the decision taken on my application or a decision whether to annul, revoke or extend a visa issued will be entered into, and stored in the Visa Information System (VIS) (1) for a maximum period of five years, during which it will be accessible to the visa authorities and the authorities competent for carrying out checks on visas at external borders and within the Member States, immigration and asylum authorities in the Member States for the purposes of verifying whether the conditions for the legal entry into, stay and residence on the territory of the Member States are fulfilled, of identifying persons who do not or who no longer fulfill these conditions, of examining an asylum application and of determining responsibility for such examination. Under certain conditions the data will be also available to designated authorities of the Member States and to Europol for the purpose of the prevention, detection and investigation of terrorist offences and of other serious criminal offences. The authority of the Member State responsible for processing the data is Urząd ds. Cudzioziemców (The Office for Foreigners), address: 16 Koszykowa St., 00-564 Warsaw. I am aware that I have the right to obtain in any of the Member States notification of the data relating to me recorded in the VIS and of the Member State which transmitted the data, and to request that data relating to me which are inaccurate be corrected and that data relating to me processing unlawfully be deleted. At my express request, the authority examining 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 corrected or deleted, including the related remedies according to the national law of the State concerned. The national supervisory authority of that Member State will hear claims concerning the protection of personal data: Inspector General for the Protection of Personal Data, 2 Stawki St., 00-193 Warsaw. I declare that to the best of my knowledge all particulars supplied by me are corrected and completed. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already granted and may also render me liable to prosecution under the law of the Member State which deals with the application. I undertake to leave the territory of the Member States before 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 Member States. The mere fact 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 Article 5(1) of Regulation (EC) No 562/2006 (Schengen Borders Code) and I am therefore refused entry. The prerequisites for entry will be checked again on entry into the European territory of the Member States. 本人知悉并同意以下条款：该申请表中所有关于本人的个人信息、照片或采集的指纹样本均为审核本人的签证所需。本人在该申请表中所填写的所有个人信息、指纹样本和照片均可提供给申根国家的相关主管部门，以便其受理本人的签证申请并对申请作出决定。 该信息以及签证结果甚或签证注销、撤消或延期的决定将一并收录到签证信息系统(1)（VIS系统）并最长保存五年，在此期间，所有申根成员国的相关签证部门、边境及境内的签证检查部门以及移民局和难民局均有权登入VIS系统，核查签证申请人是否已满足入申根国境并在境内逗留的相应前提条件；核实不满足或不再满足该前提条件的签证申请人；审核难民申请并确定出该申请的主管部门。必要时，各申根成员国的特定部门以及欧盟刑警组织均有权参考该信息，用于预防、侦察和调查恐怖活动及其它严重犯罪行为。波兰负责管理该类信息的部门是外国人管理局。（地址：Urząd do Spraw Cudzoziemców, ul. Koszykowa 16, 00-564 Warszawa）。 本人知悉本人有权要求任何一个申根成员国告知VIS系统中都收录了本人哪些个人信息，是由哪个申根成员国收录进去的。除此之外，本人亦有权申请更正系统中收录的错误信息并删除不合法信息。审核本人签证申请的领事机构会应本人要求提供相关说明性信息，如签证申请人应如何行使审核个人信息的权力，依据相关申根成员国的法律规定要求更正甚或删除不正确的个人信息的权力以及如何行使向相关申根成员国的主管部门就个人信息保护事宜依法申诉的权力。波兰负责此项事宜的部门是人信息保护局总蓝察员（地址： Generalny Inspektor Ochorny Danych Osobowych , ul. Stawki 2, 00-193 Warszawa）。 本人确保以上信息均系本人如实提供，确保信息正确而完整。本人知悉提供虚假信息可导致本人签证申请被拒签或已得到的签证被注销甚或受理本人签证的申根国会因此而对本人追究刑事责任。 如本人的签证申请被批准，本人有义务在在签证到期前离开申根国境。本人亦获悉得到签证仅是具备了进入申根国境的前提条件之一，如果本人因未满足编号为EC562/2006的欧洲共同体协定中第5条第1款中所述前提条件而被拒绝入境，本人不得要求赔偿。在进入申根成员国的领土时，入境条件将被再次审核。 Signature (for minors, signature of parental authority/legal guardian) Place and date / 地区 及 日期 签字（未成年人由其监护人代签） (1) In so far as the VIS is operational
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