Harmonised application form

Application for Schengen Visa

This application form is free1 PHOTO

Family members of EU, EEA or CH citizens or of UK nationals who are beneficiaries of the EU – UK
Withdrawal Agreement shall not fill in fields No. 21, 22, 30, 31 and 32 (marked with*).
Fields 1-3 shall be filled in in accordance with the data in the travel document.
1. Surname (Family name): FOR OFFICIAL USE ONLY

Ndombi Date of application:

Application number:
2. Surname at birth (Former family name(s)):
Application lodged at:
3. First name(s) (Given name(s)):
□Embassy/consulate
Laura Jane □ Service provider
□ Commercial
Date of birth (day-month-year): 5. Place of birth: 7. Current nationality: intermediary
Nairobi Kenyan □ Border (Name):
30 MAY 2001 Nationality at birth, ………………
6. Country of birth: if different:
□ Other:
Kenya Other nationalities:
File handled by:

Supporting documents:
8. Sex: 9. Civil status: □ Travel document
□ Male □ Single □ Married □ Registered Partnership □ Means of subsistence
□ Invitation
□ Female □ Separated □ Divorced □ Widow(er) □ TMI
□ Means of transport
□ Other □ Other (please specify):
□ Other:

10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different
from applicant’s, telephone no., e-mail address, and nationality): Visa decision:
□ Refused
□ Issued:
□A
□C
□ LTV
11. National identity number, where applicable:
38518153
□ Valid:
12. Type of travel document: From:
Until:
□ Ordinary passport □ Diplomatic passport □ Service passport
Number of entries:
□ Official passport □ Special passport
□ 1 □ 2 □ Multiple
□ Other travel document (please specify):
Number of days:

1
No logo is required for Norway, Iceland, Liechtenstein and Switzerland.
13.Number of travel document: 14. Date of issue: 15. Valid until: 16. Issued by
(country):
BK916693 01 APR 2025 31 MAR 2035 Kenya

17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who is
beneficiary of the EU – UK Withdrawal Agreement, if applicable
Surname (Family name): First name(s) (Given name(s)):
Korcek Nafula Metrine

Date of birth (day-month-year): Nationality: Number of travel document

2 JUL 1982 Kenyan or ID card:
Povolení k pobytu 001589513
18. Family relationship with an EU, EEA or CH citizen if applicable:
□ spouse □ child □ grandchild □ dependent ascendant

□ Registered Partnership □ other: Niece

19. Applicant's home address and e-mail address: Tel.:

Laura Jane Ndombi +254 740 454852
(Jane Maloba Fungututi)
EGERTON UNIVERSITY
P. O. BOX 536,
NJORO, PIAVE.
20. Residence in a country other than the country of current nationality:
□ No
□ Yes. Residence permit or equivalent ………… No. …………………….. Valid until……………

*21. Current occupation:

Assistant
* 22. Employer and employer’s address and telephone number. For students, name and address
of educational establishment:
Vipingo Industries
P.O BOX 600-80109 MTWAPA
+254 741 769895
23. Purpose(s) of the journey:
□ Tourism □ Business □ Visiting family or friends □ Cultural

□ Sports □ Official visit □ Medical reasons □ Study

□ Airport transit □ Other (please specify): Wedding gathering of my aunty Nafula Metrine
Korcek
24. Additional information on purpose of stay:
Wedding gathering
25. Member State of main destination (and other Member States 26. Member State of first
of destination, if applicable): entry:
The Czech Republic The Czech Republic

27. Number of entries requested:

□ Single entry □ Two entries □ Multiple entries

Intended date of arrival of the first intended stay in the Schengen area:
After receiving visa

Intended date of departure from the Schengen area after the first intended stay:
For 1 month.
28. Fingerprints collected previously for the purpose of applying for a Schengen visa:
□ No
□ Yes. Date, if known: ………………………………………..
Visa sticker number, if known ………………………..

29. Entry permit for the final country of destination, where applicable:

Issued by ………………………………. Valid from ……………………until ……………………

*
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):
Metrine Nafula Korcek
Jan Kabelák
Wedding gathering

Address and e-mail address of inviting person(s)/hotel(s)/temporary Telephone No.:

accommodation(s): +420 737 531 117
101 00 Praha 10 – Vršovice, Oblouková 2/956 +420 606 352 108
metrine.kabelak@gmail.com
jan.kabelak@seznam.cz

*
31. Name and address of inviting company/organisation:

Surname, first name, address, telephone no., and e-mail address Telephone No.
of contact person in company/organisation: of company/organisation:

*
32. 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:
Means of support:
□ Cash
□ referred to in field 30 or 31
□ Traveller’s cheques
□ other (please specify):
□ Credit card
□ Pre-paid accommodation
□ Pre-paid transport
Means of support:
□ Other (please specify)
□ Cash
□ Accommodation provided
□ All expenses covered
during the stay
□ Pre-paid transport
□ Other (please specify):

33. Surname and first name of the person filling in the application form, if different from the applicant:
Jan Kabelák

Adress and email address of the person filling in the Telephone No.:
application form: jan.kabelak@seznam.cz +420 606 352 108
101 00 Praha 10 – Vršovice, Oblouková 956/2
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:

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 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.

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) 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: Ministry of Foreign Affairs, Loretánské náměstí 5, CZ-118 00 Praha 1; Directorate of Alien Police, Olšanská 2, P.O.
BOX 78, CZ-130 51 Praha 3 and Ministry of the Interior, Nad Štolou 3, CZ-170 34 Praha 7.

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:
Office for Personal Data Protection, Pplk. Sochora 727/27, CZ-170 00 Praha 7, 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 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.

Place and date:

Signature of applicant:
Kenya 5 APR 2025
(Signature of parental authority/legal guardian, if applicable):