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1、Application for Schengen VisaThis application form is freePHOTO1. Surname (Family name) (x)FOR OFFICIAL USE ONLYZhang2. Surname at birth (Former family name(s) (x)Date of application:Visa application number:3. First name(s) (Given name(s) (x)SanApplication lodged at Embassy/consulate CAC4. Date of b
2、irth(day-month-year)01 JAN 20005. Place of birthBEIJING6. Country of birthCHINA7.Current nationalityCHINANationality at birth, if different: Service provider Commercial intermediary BorderName:8. Sex Male Female9. Marital status Single Married Separated Divorced Widow(er) Other (please specify) Othe
3、rFile handled by: Supporting documents:10. In the case of minors: Surname, first name, address (if different from applicants) and Travel documentnationality of parental authority/legal guardian11. National identity number, where applicable11010820000101222212. Type of travel document Ordinary passpo
4、rt Diplomatic passport Service passport Official passport Special passport Other travel document (please specify) Means of subsistence Invitation Means of transport TMI Other:Visa decision: Refused Issued: A C13. Number of travel documentG1234567814. Date of issue 15. Valid until16. Issued byExit &
5、Entry Administration Ministry of Public Security31 DEC 202101 JAN 2012 LTV Valid: From Until17. Applicants home address and e-mail addressTelephone number(s)13800138000Room XXX, No. XXX, XXX RoadHaidian District, Beijing, Chinaxxx Number of entries: 1 2 MultipleNumber of days:18. Residence in a coun
6、try other than the country of current nationality No Yes. Residence permit or equivalentNoValid until* 19. Current occupationFarmer* 20. Employer and employers address and telephone number. For students, name and address of educational establishment.Beijing XXXX Co., Ltd.Room XXX, No. XXX, XXX Road,
7、 Haidian District, Beijing, China010-8888888821. Main purpose(s) of the journey: Tourism Business Visiting family or friends Cultural Sports Official visit Medical reasons Study Transit Airport transit Other (please specify)22. Member State(s) of destinationBelgium, France23. Member State of first e
8、ntryBelgium24. Number of entries requested Single entry Two entries Multiple entries25. Duration of the intended stay or transitIndicate number of days15 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 exe
9、rcising 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 visas issued during the past three years
10、 No Yes. Date(s) of validity fromto27. Fingerprints collected previously for the purpose of applying for a Schengen visa No Yes. Date, if known28. Entry permit for the final country of destination, where applicableIssued byValid fromuntil29. Intended date of arrival in the Schengen area01 JUN 201330
11、. Intended date of departure from theSchengen area15 JUN 2013* 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 State(s)XXX HotelAddress and e-mail address of inviting person(s)/hotel(s)/tempor
12、ary accommodation(s)No.XX, XXX Road, Brussels, BelgiumserviceTelephone and telefaxTel: +32 xxxxxxxxFax: +32 xxxxxxxx*32. Name and address of inviting company/organizationTelephone and telefax of company/organizationSurname, first name, address, telephone, telefax, and e-mail address of contact perso
13、n in company/organization*33. Cost of travelling and living during the applicants stay is covered by the applicant himself/herselfMeans of support Cash Travellers cheques Credit card Pre-paid accommodation Pre-paid transport Other (please specify) by a sponsor (host, company, organisation),please sp
14、ecify referred to in field 31 or 32 other (please specify)Means of support Cash Accommodation provided All expenses covered during the stay Pre-paid transport Other (please specify)34. Personal data of the family member who is an EU, EEA or CH citizenSurnameFirst name(s)Date of birthNationalityNumbe
15、r of travel document or IDcard35. Family relationship with an EU, EEA or CH citizen spouse child grandchild dependent ascendant36. Place and dateBeijing01 APR 201337. Signature (for minors, signature of parental authority/ legal guardian)I am aware that the visa fee is not refunded if the visa is re
16、fused.Applicable in case a multiple-entry visa is applied for (cf. field no 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 States.I am aware of and consent to the following: the collection of the data req
17、uired 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 b
18、e 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 enter
19、ed 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 forcarrying out checks on visas at external borders and within the Member States, immigration and asylum authorities
20、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 longerfulfil these conditions, of examining an asylum application and of determining
21、 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 t
22、he Member State responsible for processing the data is: FPS Home Affairs, Foreigners Department, Chausse dAnvers 59b, 1000 Bruxelles Belgium.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 whic
23、h transmitted the data, and to request that data relating to me which are inaccurate be corrected and that data relating to me processed 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 per
24、sonal 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 (Commission for the Protection of Privacy - 139, rue Haute, 1000 Brussels) will hear claims concer
25、ning the protection of personal data.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 and may also render me liable to pros
26、ecution 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 M
27、ember 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.Place and dateBeijing01 APR 2013Signature(for minors, signature of parental authority/legal guardian):1Insofar as the VIS is operational.
