Ambasciata dItalia

FOTO/NH

Application for National Visa (D)/T khai xin cp th thc Quc gia
(loi D)

. .........................

This application form is free/T khai c pht min ph

1. Surname (Family name)/ (x)/ H

...........................................
2. Surname at birth (Former family names (x)) (x)/H khi sinh (H trc y)

For official use only/Mc dnh

ring cho c quan chc nng

3. First name(s) (Given name(s)) / (x) Tn

Date of application:
4. Date of birth (day-month-year)
Ngy thng nm sinh (ngy-thng-nm)

8. Sex / Gii tnh

Maschile/Nam
Femminile/N

5. Place of birth / Ni sinh

7. Current nationality / Quc tch hin ti

6. Country of birth / Quc gia sinh

Nationality at birth, if different / Quc tch

khi sinh (nu khc quc tch hin nay)

9. Married status/Tnh trng hn nhn

Single/ c thn
Married/ kt hn
Separated / Ly thn
Divorced /Ly hn
Widow(er) Ga
Other (please specify) / Tnh trng khc (xin nu r)

Visa application number:

Application lodged at:
Embassy/Consulate
Centre Municipality
Service provider
Commercial intermediary
Other
Name:

10. In the case of minors: Surname, first name, address (if different from applicant's) and nationality of parental authority/legal
guardian/ Trng hp ngi cha thnh nin: h, tn, a ch (nu khng trng vi a ch ngi xin cp th thc) v quc tch ca
ngi c quyn nui dng/ngi gim h
Responsible of the application:
File handled by:

11. National identity number, where applicable / S CMND, nu c

12. Type of travel document/Loi giy t thng hnh
Ordinary passport / H chiu ph thng
Diplomatic passport /H chiu ngoi giao
Service passport /H chiu cng v
Official passport / H chiu cng v
Special passport / H chiu c bit
Other travel document (please specify) / Giy t thng hnh khc (xin nu r):
13. Number of travel document 14. Date of issue/Ngy cp:
15. Valid until /Ngy ht hn:
16.Issued by/C quan cp:
/ S h chiu/giy t thng
hnh:
17. Applicant's home address and e-mail address of the applicant/a ch nh ring
v th in t ca ngi xin cp th thc:

Numero/i di telefono / S in thoi:

18. Residence in a country other than the country of current nationality / Bn hin c c tr ti mt quc gia khc vi quc gia m
mnh mang quc tch hin ti khng?
No/Khng
Yes/C. Residence permit or equivalent/Giy php c tr hoc giy t tng ng:
No./S .... .. Valid unti/C gi tr ti ngy..
19. Current occupation /Ngh nghip hin ti:

Supporting documents:
Travel document
Means of subsistence
Invitation
Means of transport
Medical Insurance
Other
Visa decision:
Rifused
Refused or SIS signalization.
Suspend Application
Issued
Visa type:
D

Valid:
20. Employer and employer's address and telephone number. For students, name and address of educational establishment/ Tn,
from ..
a ch v s in thoi ca c quan. i vi hc sinh, sinh vin: tn v a ch trng:
to .
21. Main purpose(s) of the journey /(Cc) mc ch chnh ca chuyn i
Family reunion/Accompanied family/on t gia nh/i theo thnh vin gia nh
Religious purpose/Mc ch tn gio
Medical reason/L do y t
Autonomy working/Lm vic c lp

Sport/Th thao
Mission/i theo phi on
Diplomatic/ Ngoi giao
Study/i hc
Adoption/Con nui
Subordinate working/Lm vic
Other (please specify)/Mc ch khc (xin nu r)

Number of entries:
1
2
Multiple

(x) From box 1 to 3, information shall be declared as indicated in the travel document /T mc s 1 n s 3, ngh khai cc thng tin nhu
nu trong loi giy t thng hnh

22. City of destination/Thnh ph ni n:

23. Member State of first entry/Nc thnh vin s nhp cnh u

tin:

24. Number of entries requested/S ln nhp cnh yu

cu:

25. Duration of the stay. Indicate number of days (max. 365 days) /
Thi gian d nh lu tr. Ghi r s ngy (ti a 365 ngy):

S in gl e e n tr y/ M t l n
Two e nt r y/ H a i l n
Multiplee entry/Nhiu ln
26. Schengen visas issued during the past three years / Th thc Schengen c cp trong ba nm tr li gn y:
N o/ K h n g
Yes/C Date(s) of validity

from/c gi tr t ngy ..............................to/n ngy...............................................

27. Fingerprints collected previously for the purpose of applying for a Schengen visa/Bn tng c ly du vn tay khi
xin cp th thc Schengen cha?
No/Cha
Yes/Ri
Date, if known/Thi gian, nu bit:

28. Authorization number issued for Family Reunion/Accompanied Family/Subordinate Working (only when applicable by
national law) /S cp php cho th thc xin on t gia nh/i cng thnh vin gia nh/i lm vic:
Issued by SUI of /do c quan SUI no cp:
Valid from/c gi tr t ngy: .............................................
29. Intended date of arrival in the Schengen area/Ngy d
nh nhp cnh vo khi Schengen:

to/n ngy ......

30. Intended date of departure from the Schengen area (only for
the visa of duration from 91 to 364 days)/ Ngy d nh xut
cnh khi khi Schengen (ch dnh cho th thc c gi tr t 91
n 364 ngy)
31. Surname and first name of the person who requested the reunion..........................................................
or employer. Otherwise, in case of visa for Adoption,
Religious purpose, Medical purpose, Sport, Study, Mission: address of ......in Italy/ H v tn ca ngi yu cu on t
hoc c quan. Trong trng hp nu l th thc mc ch xin con nui, tn gio, iu tr bnh, th thao, i hc, i theo phi
on, a ch ti Italy:
Address and email address of the person requested the reunion Telephone or telefax of the person requested the reunion or
employer/S in thoi v s fax ca ngi yu cu on t
or employer/a ch v e.mail ca ngi yu cu on t hoc
hoc ca c quan:
ca c quan:

32. Name and address of inviting company/organization /Tn

v a ch ca c quan/t chc mi:

Telephone or telefax of inviting company/organization/S

in thoi v s fax ca c quan/t chc mi:

Surname, first name, address, telephone, telefax and email address of contact person in company/organization/H v tn, a
ch, s in thoi v s fax ca ngi lin h trong c quan/t chc mi:
...........................................................................................................................................................................................................
33. Cost of traveling and living during the applicant's stay is covered/Chi ph i li v n ca ngi xin cp th thc trong
thi gian lu tr s c chi tr
by the applicant himself/herself/bi chnh ngi xin cp th
thc
Means of support/Hnh thc thanh ton:
Cash/Tin mt
Traveller's cheques/Sc du lch
Credit card/Th tn dng
Prepaid accommodation/Ch c tr tin
Prepaid transport/Phng tin i li c tr tin
Other (please specify)/Hnh thc khc (xin nu r)

by a sponsor (host, company, organization), please

specify/bi mt n v bo lnh (ngi mi, c quan, t chc),
xin nu r
referred to in field 31 or 32/c nu trong mc 31 hoc
32
other (please specify)/bn khc (xin nu r)
Means of support/Hnh thc thanh ton:
Cash/Tin mt
Accommodation provided/Ch c chu cp
All expenses covered during the stay/Chu cp tt c cc chi
ph trong thi gian lu tr
Prepaid transport/Phng tin i li c tr
tin
Other (please specify)/Hnh thc khc (xin nu r)

NO NEED OF INDICATION IN CASE REQUESTING

VISA OF:/KHNG CN KHAI TRONG TRNG HP XIN
TH THC:
Family reunion, Accompanied family, Subordinate/Selfemployed work, Mission, Diplomatic, Adoption./on t gia
nh, i cng thnh vin gia nh/Lm vic c lp, i theo
phi on, Ngoi giao, Con nui.

34. Personal data of the family member who is an EU, EEA or CH citizen/ Thng tin c nhn ca thnh vn gia nh l cng dn EU,
EEA hoc Thy S:
Surname /H
Date of birth / Ngy thng nm sinh

First name (s) / Tn

Nationality /Quc tch

Number of travel document or ID card/

Giy t thng hnh hoc CMND s

35. Family relationship with EU, EEA or CH citizen / Quan h h hnh vi cng dn EU, khi kinh t chu u hoc Thy S:
spouse/v/chng
oth e r di r e c t de sc e nda nt /con chu khc sng ph thuc
36. Place and date / Ngy v ni lm n

child / con
de pe nda nt a sc e n da n t /cha, m, ng, b sng ph thuc
37. Signature (for minors, signature of parental authority/legal
guardian) Ch k (i vi ngi cha n tui thnh nin, ch k
ca ngi c quyn nui dng/gim h)

I am aware that the visa fee is not refunded if the visa is refused/Ti nhn thc r rng l ph xin cp th thc s khng c hon li nu n xin cp
th thc b t chi
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 purpose of a decision on my visa application.
Ti nhn thc r v ng rng: Trong qu trnh xt h s xin cp th thc, vic cung cp nhng thng tin yu cu trong t khai xin cp th thc, chp
nh v ly du vn tay ca ti trong trng hp cn thit l bt buc mi thng tin c nhn nu trong t khai cng nh du vn tay v nh ca ti s c
chuyn n v c x l bi cc c quan chc nng ca cc nc thnh vin nhm mc ch a ra quyt nh i vi n xin cp th thc ca ti.
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 informatics system of the Diplomatic Consulate Representative or of the Ministry of Foreign Affairs. These data
will be accessible to the national 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 o verifying whether the conditions for the legal entry
into, stay and residence on the territory of the Member States are fulfilled, or identifying persons who do not or who non longer fulfill these
conditions, of examining an asylum application and of determining responsibility for such examination. Under certain conditions, the data will be
available to designated authorities of the Member States and to Europol for the purpose of the prevention, detection and investigation of terrorist
offences and other serious criminal offences.
Nhng d liu ny cng nh nhng thng tin lin quan ti quyt nh v n xin cp th thc ca ti hoc lin quan ti quyt nh hy b, thu hi hay gia
hn th thc s c nhp v lu tr trong h thng C quan Lnh s Ngoi giao hoc B Ngoi giao. Nhng d liu ny gip cc c quan cp th thc
quc gia v cc c quan c thm quyn kim tra th thc ti bin gii bn ngoi v trong phm vi cc nc thnh vin cng nh cc c quan qun l xut
nhp cnh v t nn ca cc nc thnh vin c th xc minh xem cc iu kin nhp cnh v lu tr hp php ti cc nc thnh vin c c p ng
hay khng, nhn dng nhng c nhn khng hoc khng cn p ng c nhng yu cu , kim tra n xin t nn v quyt nh v thm quyn trong
vic kim tra. Di nhng iu kin nht nh, cc c quan c thm quyn c ch nh ca cc nc thnh vin v Europol cng c th truy cp nhng
thng tin v d liu ny nhm mc ch phng chng, pht hin v iu tra cc ti phm khng b v cc hnh vi nguy him khc.
I am aware that I have the right to obtain any of the Member States notification of the data relating to me recorded in the informatics system, 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.
The national supervisory authority of the data is " il Garante per la Protezione dei Dati Personali".
Ti bit r rng ti c quyn yu cu ti bt c nc no trong cc quc gia thnh vin thng bo v cc d liu lin quan n ti c lu tr trong h
thng my tnh, v c quyn yu cu chnh sa cc d liu khng chnh xc lin quan ti c nhn ti cng nh xa cc d liu lin quan ti ti b x l
mt cch phi php. Khi ti yu cu bng vn bn, c quan th l n ngh ca ti s thng bo vi ti cch thc ti c th thc hin quyn kim tra cc
d liu c nhn lin quan ti ti v chnh sa hay xa b chng, bao gm cc phng tin php l theo lut php ca quc gia thnh vin c lin quan. C
quan gim st quc gia cc d liu l:" il Garante per la Protezione dei Dati Personali".
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
State (article 331 c.p.p).
Ti cam oan vi tt c s hiu bit ca mnh rng nhng thng tin m ti cung cp l ng v y . Ti thc r rng bt c thng tin khai man no
cng dn ti vic h s xin cp th thc ca ti b t chi hoc th thc cp cho ti b hy b v ti c th b truy t hnh s theo lut php ca quc gia
(iu 331 c.p.p).
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, paragraph 1 of Regulation (EU) no. 562/2006 (Schengen Borders Code) and article 4 of the D.Lgs. 286/98 and I am
therefore refused entry.
Vic c cp th thc khng c ngha l ti c quyn bi thng nu ti b t chi nhp cnh do khng p ng c cc iu kin nu trong iu 5
khon 1 Lut s 562/2006 (Lut Bin gii Schengen) v iu 4 Lut D.Lgs 286/98.

NOTA (For official use only)/

.
GHI CH (ch dng cho vn phng
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................
Place and date / Ni cp v ngy cp

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

Ch k (i vi ngi cha n tui thnh nin, ch k ca ngi c quyn
nui dng/gim h)