Application for Schengen Visa
申根签证申请表
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Family members of EU, EEA or CH citizens shall not fill in fields no.21, 22, 30, 31 and 32 (marked with*).
欧盟，欧洲经济区或瑞士联邦公民家属不填写第21,22,30,31及32项（*标注）
Fields 1-3 shall be filled in in accordance with the data in the travel document. 第1-3项须按照旅行证件信息填写。 1. Surname (Family name): 姓氏: FOR OFFICIAL USE ONLY 签证机关专用 2. Surname at birth (Former family name(s)): 出生时姓氏: Data złożenia wniosku: Numer wniosku: 3. First name(s) (Given name(s)): 名字: □4. Date of birth 5. Place of birth: 7. Current nationality: 现国籍: □ w ambasadzie lub konsulacie we wspólnym ośrodku(day-month-year): 出生地点: 出生日期(日-月-年): □□ przyjmowania wnioskó w u usługodawcy Nationality at birth, if different: u pośredniczącego podmiotu 6. Country of birth: 出生时国籍，如不同: 出生国: □ komercyjnego na granicy Other nationalities: 其他国籍: Nazwa: □ inne 8. Sex: 性别: 9. Marital status: 婚姻状况: □ Male 男 □ Female 女 □ Single 单身 □ Married 已婚 □ Registered Partnership Wniosek przyjęty przez: 注册伴侣关系 □ Separated 分居 □ Divorced 离异 □Dokumenty uzupełniające: Widow(er) 丧偶 □ Other (please specify): 其他（请注明): □□ dokument podróży10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different from applicant’s, □ środki utrzymania telephone no., e-mail address, and nationality): □ zaproszenie środek transportu 父母（如是未成年申请人）/合法监护人（姓名、住址，如与申请人不同)电话号码、电子邮件及国籍: □ podróżne ubezpieczenie □ medyczne inne: 11. National identity number, where applicable: 公民身份证号码，如适用: Decyzja o wizie: □□ odmowa wydania wizy 12. Type of travel document: 旅行证件类型: □ Ordinary passport 普通护照 □ Diplomatic passport 外交护照 □ Service passport 公务护照 □ wiza przyznana: □ □ Official passport 因公护照 □ Special passport 特殊护照 □ A C o ograniczonej ważności □ terytorialnej Other travel document (please specify) 其他旅行证件（请注明): 13. Number of travel document: 14. Date of issue: 15. Valid until: 16. Issued by: □ Termin ważności: 旅行证件号码: 签发日期: 有效期至: 签发机关: Od ……………………………. Do ……………………………. 17. Personal data of the family member who is an EU, EEA or CH citizen: 如有家庭成员为欧盟、欧洲经济区或瑞士联邦公民的，请填写该家庭成员的个人信息: Liczba wjazdów: □ 1 □ 2 □ wielokrotny Surname (Family name): 姓氏: First name(s) (given name(s)): 名字: Liczba dni: .................... Date of birth: Nationality: 国籍: Number of travel document of ID card: 出生日期（日-月-年): 旅行证件或个人身份证件号码: 18. Family relationship with an EU, EEA or CH citizen: 申请人与欧盟，欧洲经济区或瑞士联邦公民亲属关系，如涉及: □ spouse 配偶 □ child 子女 □ grandchild 孙子女 □ dependent ascendant 赡养的老人 □ registered partnership 注册伴侣关系 □ other 其他: 19. Applicant’s home address and e-mail address: 申请人家庭住址及电子邮件地址: Telephone number(s): 电话号码: 20. Residence in a country other than the country of current nationality: 在现国籍以外国家居住: □ No 否 □ Yes 是 Residence permit or equivalent 居留许可或同等证件 ........................................ No. 号码..............................Valid until 有效期至................................................. * 21. Current occupation: 现职业: * 22. Employer and employer’s address and telephone number. For student, name and address of educational establishment: 工作单位的名称，地址和电话号码。如是学生，请填写教育机构名称及地址： 23. Main purpose(s) of the journey: 旅行目的: □ Tourism 旅游 □ Business 商务 □ Visiting family or friends 探亲访友 □ Cultural 文化 □ Sports 体育 □ Official visit 官方出访 □ Medical reason 医疗 □ Study 学习 □ Airport transit 机场过境 □ Other (please specify) 其他（请注明): 24. Additional information on purpose of stay: 关于逗留目的的补充信息: 25. Member State of main destination (and other Member States of destination, if applicable): 主要目的地申根成员国 （及其他目的地申根成员国，如适用): 26. Member State of first entry: 首入申根成员国: 27. Number of entries requested: 申请入境次数: □ Single entry 单次 □ Two entries 两次 □ Multiple entries多次 Intended date of arrival of the first intended stay in the Schengen area: 在申根地区预计首次停留的预计抵达日期: Intended date of departure from the Schengen area after the first intended stay: 在申根地区预计首次停留之后的 预计离开日期: 28. Fingerprints collected previously for the purpose of applying for a Schengen visa: 此前申请申根签证时是否有指纹记录: □ No 否 □ Yes 是 Date, if known 日期，如知晓…………………….. Visa sticker number, if known 签证贴纸号码，如知晓 ……………………………………… 29. Entry permit for the final country of destination, where applicable: 最终目的地国入境许可，如适用: Issued by 签发机关…………………………………………………………………………………… Valid from 有效期自…………………………………………until 至 ……………………………… * 30. 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): 申根成员国邀请人姓氏及名字。如不适用， 请填写在申根成员国酒店或暂住居所名称: Address and e-mail address of inviting person(s)/hotel(s)/temporary accommodation(s): 邀请人/酒店/暂住居所地址及电子邮件地址: Telephone no.: 电话号码: * 31. Name and address of inviting company/organisation: 邀请公司/机构名称及地址: Surname, first name, address, telephone, telefax, and e-mail Telephone and telefax of company/organisation: 邀请公司/机构联系电话: address of contact person in company/organisation: 邀请公司/机构联系人姓氏，名字，地址，电话号码及 电子邮件地址: * 32. Cost of travelling and living during the applicant’s stay is covered: 申请人旅费以及停留期间的生活费用由: □ by the applicant himself/herself 申请人自己承担 □ by a sponsor (host, company, organisation), please specify 由赞助人（邀请人，公司，机构）承担，请注明: ..................................... Means of support: 支付方式: □ Cash 现金 □ Traveller‘s cheques 旅行支票 □ Credit card 信用卡 □ Prepaid accommodation 预付住宿 □ Prepaid transport 预付交通 □ Other (please specify): 其他(请注明): □ referred to in field 31 or 32 30 or 31参见第30及31项 ..................................... □ other (please specify) 其他（请注明）: Means of support: 支付方式: □ Cash 现金 □ Accommodation provided 预付住宿 □ All expenses covered during the stay 支付旅行期间全部费用 □ Prepaid transport 预付交通 □ Other (please specify): 其他(请注明）:
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 适用于申请多次入境签证: 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. 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 application; and any personal data concerning me which appear on the 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 application. 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。 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 (1) (VIS) 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: Centralny Organ Techniczny KSI, Komenda Główna Policji, Puławska 148/150, 02-624 Warszawa. 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。负责处理这些数据的申根 成员国主管机构为：国家信息系统中央技术技术 管理局，警察总署，Puławska 大街 148/150 号，02-624，华沙。 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 Member State concerned. The national supervisory authority of that Member State: Inspector General for the Protection of Personal Data, 2 Stawki St., 00-193 Warsaw will hear claims concerning the protection of personal data. 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，并向相关申根成员国 的主管部门 [详细联系信息：个人信息保护局总监察员，Stawki 大街 2 号，00-193，华沙。就个人信息保护事宜依法申诉的权力。 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. 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。 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 6(1) of Regulation (EU) No 2016/399 (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. 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(EU) No. 2016/399的《申根边境法》中第6条第1款中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。 Place and date: 地点及日期: Signature: 签名: (signature of parental authority/legal guardian, if applicable): （未成年人父母/法定监护人签字，如适用）:
1 In so far as the VIS is operational.
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