Harmonised application form

Application for Schengen Visa

This application form is free.

1 Surname (Family name) (x) F OR OFFICIAL USE ONLY

RUBEL
2 Surname at birth (Former family name(s)) (x) Date of application:

RUBEL Visa application number:

3 First name(s) (Given name(s)) (x)

RUBEL
4 Date of birth (day-month-year) 5 Place of birth 7 Current nationality Application lodged
Nationality at birth, if Embassy/consulate
BRAHMANVARIA
02/03/1985 6 Country of birth CAC
DUBAI
BANGLADESHI Service provider
8 Sex 9 Marital status
Commercial
Y Male Female Single U Married Separated Divorced Widow(er)
Border
Other (please specify)

Name:

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

File handled by:

11 National identity number, where applicable

12 Type of travel document Supporting documents:

Ordinary passport Diplomatic passport Service passport Y Official passport Special passport Travel document

Other travel document (please specify) Means of subsistence

Invitation

Means of transport
13 Number of travel document 14 Date of issue 15 Valid until 16 Issued by
TMI
EL0856744 08/08/202 07/09/202 DHAKA Other:
17 Applicant's home address and e-mail address Telephone number(s)
Visa decision:
Refused
+971566524380
Issued:
18 Residence in a country other than the country of current nationality A
Y No C
Yes. Residence permit or equivalent No. 04/04/202 Valid until
LTV
03/04/2024
* 19 Current occupation Valid:
From

* 20 Employer and employer's address and telephone number. For students, name and address of educational establishment.
Until

21 Main purpose(s) of the journey:

Visiting family or friends Cultural Sports Number of entries:
Tourism Business
1 2 Multiple
Official visit
Number of days:
Medical reasons
Study Transit Airport transit Other (please specify)

(1) No logo is required for Norway, Iceland and Switzerland.

22 Member State(s) of destination 23 Member State of first entry

24 Number of entries requested 25 Duration of the intended stay or transit

Single entry Indicate number of days
Two entries

Multiple entries

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 visas issued during the past three years

No

Yes. Date(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

Issued by Valid from until

29 Intended date of arrival in the Schengen area 30 Intended date of departure from the Schengen area

* 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)

Address and e-mail address of inviting Telephone and telefax

person(s)/hotel(s)/temporary accommodation(s)

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

Surname, first name, address, telephone, telefax, and e-mail address of contact person in company/organisation

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

by the applicant himself/herself by a sponsor (host, company, organisation), please specify

referred to in field 3 1 or 3 2
Means of support

Cash other (please specify)

Traveller's cheques
Means of support
Credit card
Cash
Pre-paid accommodation
Accommodation provided
Pre-paid transport
All expenses covered during the stay
Other (please specify)
Pre-paid 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 or ID card

35 Family 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 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 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 fulfil 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 the Danish Immigration Service, Ryesgade 53, DK-2100 Copenhagen Ø, Denmark, e-mail:
[email protected].

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 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
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 (the Danish Data Protection Agency, Borgergade 28, 5, DK-1300 Copenhagen K, Denmark, e-
mail: [email protected]) will hear claims concerning 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 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.

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

(1) In so far as the VIS is operational