APPLICATION FOR SCHENGEN VISA
PHOTO THIS APPLICATION FORM IS FREE
سحٛاٌظ ٓشح شٕج١اسزّبسح ؽٍت رأش
ِجبٔبٝاسزّبسح رؼط
1. Surname (Family name) (x) FOR OFFICIAL USE ONLY
Masood
)x( اسُ اٌؼبئٍخٚ اٌٍمت أ-1 جضء خبص ثبإلداسح
2. Surname at birth (Former family name(s)) (x) Date of application:
N/A )x( اٌسبثكٚالد أ١ٌّ اسُ اٌؼبئٍخ ػٕذ اٚ اٌٍمت أ-2
3. First name(s) (Given name(s)) (x) Visa application number:
Islam )x( ُ االس-3
4. Date of birth (day-month-year) 5. Place of birth الد١ٌّ ِحً ا-5 7.Current nationality
)اٌسٕخ-شٙاٌش-َٛ١ٌالد (ا١ٌّخ ا٠ ربس-4 خ١ٌخ اٌحب١ اٌجٕس-7
Gaza Palestinian Application lodged at
05-07-2000 □ Embassy/consulate
6. Country of birth الد١ٌّ ثٍذ ا-6 Nationality at birth, if diffe □ CAC
rent:
Palestine □ Service provider
خ١ٌخ اٌحب١ إرا وبٔذ رخزٍف ػٓ اٌجٕس،الد١ٌّخ ػٕذ ا١اٌجٕ س
□ Commercial intermediary
8. Sex عٌٕٛ ا-8 9. Marital status خ١ اٌحبٌخ االجزّبػ-9
□ Border
✓
□ Male/ □ روشFemale/ٝأٔث ✓
□ Single/ □ اػضةMarried/جٚ □ ِزضSeparated/ً □ ِٕفظDivorced/ِطٍك
□ Widow(er)/ًِ □ أسOther (please specify)/)ػّحٚ( ش رٌه١غ
Name:
10. In the case of minors: Surname, first name, address (if different from applicant´s) and nationality of
parental authority/legal guardian
خ١ٔٛٔخ اٌمب٠طبٌٛ ثبٚٓ أ٠اٌذٌٛق اَٛ ثّّبسسخ قمٛم٠ ٞخ اٌشخض اٌز١ جٕسٚ )شح١بٔبد ؽبٌت اٌزأش١اْ (إرا وبٔذ رخ زٍف ػٓ ثٕٛ اٌؼٚ ُ االسٚ اٌٍمت: ٌٍمظّش-11 □ Other
N/A File handled by:
11. National identity number, where applicable خ١ك اٌشخظ١ سلُ ثطبلخ رحم-11
Supporting documents:
405994161 □ Travel document
□ Means of subsistence
12. Type of travel document :اص اٌسفشٛع جٛٔ-12
□ Invitation
✓
□ Ordinary passport/ٜ □ ػبدDiplomatic passport/ِٟبسٍٛ □ دثService passport/ّخٌّٙ
□ Means of transport
□ Official passport/ّٟ □ سسSpecial passport/خبص
□ TMI
□ Other travel document (please specify)/)ذ٠ش رٌه (ثشجبء اٌزحذ١غ
□ Other:
13. Number of travel document 14. Date of issue 15. Valid until 16. Issued by
اص اٌسفشٛ سلُ ج-13 خ اإلطذاس٠ ربس-14 بءٙخ االٔز٠ ربس-15 خ اإلطذاسٙ ج-16
5929879 15-08-2023 14-08-2028 The Palestinian Authority
17. Applicant's home address and e-mail address Telephone number(s) Visa decision:
شح١ ٌطبٌت اٌزأشٟٔٚذ اإلٌىزش٠اْ اٌجشٕٛ ػٚ ٞذ٠اْ اٌجشٕٛ اٌؼ-17 +201094692349 ْٛف١ٍ □ أسلبَ اٌزRefused
16 Dr Sobki Street, Dokki, Cairo, Egypt. islammasood18@gmail.com +201027072595
18. Residence in a country other than the country of current nationality ٍٟؽٕه األطِٛ س١ٌ ثٍذُٟ ف١ً٘ أٔذ ِم-18 □ Issued:
✓
□ No/ال □A
□ Yes. Residence permit or equivalent/ ُح إلبِخ سل٠ٔؼُ رظش □C
□ No. …………………….. Valid until/ٝزٗ قز١ طالقٚ □ LTV
1
19. Current occupation خ١ٌفخ اٌحب١ظٌٛ ا-19*
Medical student □ Valid:
* 20. Employer and employer's address and telephone number. For students, name and address of From
educational establishment. اْ ِىبْ اٌذساسخٕٛ ػٚ ُ ثبٌٕسجخ ٌٍطٍجخ اس.ْ اٌششوخٛف١ٍ سلُ رٚ ْإٛ ػٚ ُ (*) اس-21 Until
Al-Azhar university, Gaza, Palestine
21. Main purpose(s) of the journey: :اٌغشع ِٓ اٌسفش-21 Number of entries:
✓
□ Tourism/بقخ١ □ اٌسBusiness/ًّ □ اٌؼVisiting family or friends/ األطذلبءٚبسح األلبسة أ٠ ص.□ Cultural/ ٌٟغشع ثمبف □ 1 □ 2 □ Multiple
□ Sports/ٟبػ٠ □ ٌغشع سOfficial visit/خ١ّبسح سس٠ □ صMedical reasons/ □ ٌٍؼالجStudy/ □ ٌٍذساسخTransit/ذ٠رشأض
□ Airport transit/ذ ثبٌّطبس٠ □ رشأضOther (please specify)/)ذ٠ٌغشع آخش (ثشجبء اٌزحذ Number of days:
x Fields 1-3 shall be filled in in accordance with the data in the travel document اص اٌسفشٛ جٟس فٛ ِزوٛ٘ فمب ً ٌّبٚ رّأل3 ٌٝ إ1 ِٓ ( إٌمبؽx)
1 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.
ُٙا قمّٛبسس٠ ٚ ْٚسبفش٠ ٓ٠ األلبسة)اٌز- األؽفبي-جخٚاٌض/جٚ (اٌضٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ اإلرحبد األٟٕاؽِٛ رحًّ ػالِخ (*) ِٓ لجً أفشاد ػبئٍخٟ األسئٍخ اٌزٍٝزُ اإلجبثخ ػ٠ * ال
.35 ٚ 34 إٌمبؽٍٝ اإلجبثخ ػٚ ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ االرحبد األٟٕاؽُّٛ ثٙثجذ طٍخ لشاثز٠ ُ ِب٠ُ رمذٙ١ٍ ٌىٓ ػٚ ًخ اٌزٕم٠ قشٟف
22. Member State(s) of destination دحٛخ اٌسفش اٌّمظٙ ج-22 23. Member State of first entry
٘زٖ اٌشقٍخٟب فٌٙٛزُ دخ٠ ٌخٚي دٚ أ-23
Greece Greece
24. Number of entries requested ثخٍٛي اٌّطٛ ػذد ِشاد اٌذخ-24 25. Duration of the intended stay or
□ Single entry/اقذحٚ ِشح. □ Two entries/ٓ١ ِشر. transit
✓Multiple entries/ِزؼذدح
□ :ذ٠ اٌزشأضٚ ِذح اإللبِخ أ-25
05/07/2024 - 29/07/2024 (25 days)
Indicate number of days
ثخٍٛبَ اٌّط٠ذ ػذد األ٠ثشجبء رحذ
26. Schengen visas issued during the past three years شح١اد األخٕٛب خالي اٌثالس سٙ١ٍي ػٛشاد شٕجٓ رُ اٌحظ١ رأش-26
□ No/ال
05-11-2023 05-01-2024
✓Yes. Date(s) of validity from ………………… . to/......ٌٝإ..... خ ِٕز١خ اٌظالق٠ ربس.ُٔؼ
□
27.Fingerprints collected previously for the purpose of applying for a Schengen visa
شح١ً٘ ُؽٍت أخز ثظّبد األطبثغ ِٓ أجً ؽٍت رأش-27
□ No/□……………………………… ال ✓ Yes/ُ ٔؼ.
……………………………………. Date, if known/ ٗ إرا وٕذ رؼشف،خ٠اٌزبس
28. Entry permit for the final country of destination, where applicable
) اٌسفش (إرا ٌضَ األِشٟخ ف١س١خ اٌشئٙجٌٛ رؼزجش اٌٟخ اٌزٚي اٌذٛح دخ٠ رظش-28
Issued by/ ٓ……………………………… طبدس ػ..Valid from/ِٓ خ١………………………… اٌظالقuntil/ٝ……………………… قز
29. Intended date of arrival in the Schengen area 30. Intended date of departure from the
ٓي ِٕطمخ اٌشٕجٛخ دخ٠ ربس-29 Schengen area
05-07-2024
29-07-2024 ٓج ِٓ ِٕطمخ اٌشٕجٚخ اٌخش٠ ربس-31
*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)
ٓي اٌشٕجٚاْ اٌّؤلذ ٌإللبِخ ثذٕٛ اٌؼٚ اسُ اٌفٕذقٌٚخ اٌشٕجٓ أٚف ثذ١ ٌمت اٌشخض اٌّؼٚ ُ اس-31 *
National and Kapodistrian University of Athens
Accomidations at: Amalia Hotel, Europa Hotel, Agamemnon Hotel and Lesvion Hotel
Address and e-mail address of inviting person(s)/hotel(s)/temporary Telephone and telefax
accommodation(s) اٌفبوسٚ ْٛف١ٍسلُ اٌز
ٌّمش اإللبِخ اٌّؤلزخٚ ٌٍفٕذق أٚف أ١ ٌٍشخض اٌّؼٟٔٚذ اإلٌىزش٠اْ اٌجشٕٛ ػٚ ٞذ٠اْ اٌجشٕٛاٌؼ
Leoforos Vasilisis Amalias 10, Athina 105 57, Greece Phone: +30 12 0323 7300
E-mail: reserve@amaliahotels.com
*32. Name and address of inviting company/organisation Telephone and telefax of
حٛ أطذسد اٌذػٟخ اٌزٙاْ اٌجٕٛ ػٚ ُ اس-32* company/organisation
ٚ اٌفبوس اٌخبص ثبٌششوخ أٚ ْٛف١ٍأسلبَ اٌز
National and Kapodistrian University of Athens إٌّظّخ
Academias 45, Athens 10676
T: (+30) 2103688627
Surname, first name, address, telephone, telefax, and e-mail address of contact person in
company/organisation
ٟٔٚذ اإلٌىزش٠اْ اٌجشٕٛ ػ- اٌفبوس-ْٛف١ٍ سلُ اٌز-ْإٛ اٌؼ- اٌٍمت-ُ االس: إٌّظّخٚزظً ثه ِٓ داخً اٌششوخ أ٠ ٞبٔبد اٌشخض اٌز١ث
Professor Maria Gavouneli, T: (+30) 2103688627, E: mgavoun@law.oa.gr, summerschool-rms@uoa.gr
*33. Cost of travelling and living during the applicant's stay is covered
:بٍّٙزح٠ فٛشح خالي فزشح إلبِزٗ س١ سجً اإلػبشخ ٌطبٌت اٌزأشٚ ف اٌسفش١ٌ رىب-33*
□ by the applicant himself/herself/ٗاٌشخض ٔفس ✓by a sponsor (host, company,
□
organisation), please specify
ٚف أ١ذ إرا وبْ اٌشخض اٌّؼ٠ي (ثشجبء رحذِّٛ ك٠ػٓ ؽش
) إٌّظّخٚاٌششوخ أ
Means of support/سجً اإلػبشخ
✓referred to in field 31 or 32
□
32 ٚ أ31 اٌجٕذٟبٔبرٗ ف١سح ثٛاٌشخض اٌّزو
□ Cash/خ٠ِجبٌغ ٔمذ
□ other (please specify)
□ Traveller's cheques/خ١بق١ىبد س١ش )ذ٠شٖ (ثشجبء اٌزحذ١غ
□ Credit card/ْثطبلخ ائزّب Means of support/سجً اإلػبشخ
□ Pre-paid accommodation/ِٗىبْ اإللبِخ رُ دفؼ □ Cash/خ٠ِجبٌغ ٔمذ
□ Pre-paid transport/بٙاٌزٕمالد رُ دفؼ ✓Accommodation provided
□
□ Other (please specify)/)ذ٠ش رٌه (ثشجبء اٌزحذ١غ شح١زُ اٌحجض ٌطبٌت اٌزأش١س
✓All expenses covered during the stay
□
ًِف اٌسفش ِغطبٖ ثبٌىب١ٌرىب
✓Pre-paid transport/بٙاٌزٕمالد رُ دفؼ
□
□ Other (please specify)
)ذ٠ش رٌه (ثشجبء اٌزحذ١غ
34. Personal data of the family member who is an EU, EEA or CH citizen
ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ اإلرحبد األٟٕاؽِٛ ِٓ خ ألقذ األلبسة١بٔبد اٌشخظ١ اٌج-34
1 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.
ُٙا قمّٛبسس٠ ٚ ْٚسبفش٠ ٓ٠ األلبسة)اٌز- األؽفبي-جخٚاٌض/جٚ (اٌضٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ اإلرحبد األٟٕاؽِٛ رحًّ ػالِخ (*) ِٓ لجً أفشاد ػبئٍخٟ األسئٍخ اٌزٍٝزُ اإلجبثخ ػ٠ * ال
.35 ٚ 34 إٌمبؽٍٝ اإلجبثخ ػٚ ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ االرحبد األٟٕاؽُّٛ ثٙثجذ طٍخ لشاثز٠ ُ ِب٠ُ رمذٙ١ٍ ٌىٓ ػٚ ًخ اٌزٕم٠ قشٟف
Surname/اٌٍمت First name(s)/ُاالس
Date of birth/الد١ٌّخ ا٠ربس Nationality/خ١اٌجٕس Number of travel document or
ID card
خ١ك اٌشخظ١ رحمٚاص اٌسفش أٛسلُ ج
35. Family relationship with an EU, EEA or CH citizen
ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚاؽٓ اإلر حبد األِٛ طٍخ اٌمشاثخ ِغ-35
□ spouse/جخٚص/جٚ ص.□ child/ٓ □…… اثgrandchild/ذ١ □……………… قفdependent ascendant/جذ
36. Place and date ْ اٌّىبٚ خ٠ اٌزبسٟشا ف٠ رحش-36 37. Signature (for minors, signature of parental
authority/legal guardian)
غ أقذ١لَٛ ثبٌزٛم٠ ً شح لبطشا١ قبٌخ إرا وبْ ؽبٌت اٌزأشٟغ (ف١لٛ اٌز-37
30-06-2024, Cairo, Egypt )ٗ١ٍ ػٟطٌٛ اٌشخض اٚٓ أ٠اٌذٌٛا
1 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.
ُٙا قمّٛبسس٠ ٚ ْٚسبفش٠ ٓ٠ األلبسة)اٌز- األؽفبي-جخٚاٌض/جٚ (اٌضٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ اإلرحبد األٟٕاؽِٛ رحًّ ػالِخ (*) ِٓ لجً أفشاد ػبئٍخٟ األسئٍخ اٌزٍٝزُ اإلجبثخ ػ٠ * ال
.35 ٚ 34 إٌمبؽٍٝ اإلجبثخ ػٚ ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ االرحبد األٟٕاؽُّٛ ثٙثجذ طٍخ لشاثز٠ ُ ِب٠ُ رمذٙ١ٍ ٌىٓ ػٚ ًخ اٌزٕم٠ قشٟف
I am aware that the visa fee is not refunded if the visa is refused. .إنني على علم بأنه في حالة رفض التأشيرة ال يحق لي استرجاع قيمة التأشيرة
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.
:)24 ُشح اٌّزؼذدح (أٔظش اٌجٕذ سل١ٌطبٌت اٌزأش
ٓبساد اٌالقمخ داخً اٌشٕج٠خض اٌض٠ ً ٕب١ِ أْ ألذَ رأٟٕجغ٠ ٚ ٓ ِٕطمخ اٌشٕجٟ داخً أساػٌٝٚ األٟٕبست ِذح إلبِز٠ ٓ ٌٍسفش١ِ رأٍٝ أْ أقظً ػٍٝ ػٟٕجغ٠ ٗٔ ػٍُ ثأٍٝ ػٟٕٔإ
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)2 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 Greece
responsible for processing the data is: Ministry of Foreign Affairs, C4 Directorate, 1 Vas. Sofias Ave. GR 10671 Athens,
Tel.:+30.210.3684515, Fax:+30.210.3684180, Email: g04@mfa.gr. 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 {Hellenic Data Protection Authority, Kifisias str 1-3, 1st
floor, GR – 115 23 Athens, Tel.: +30.210.6475600, Fax:+30.210.6475628, E-mail: contact@dpa.gr} 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.
شح اٌخبص١ ٌذساسخ ؽٍت اٌزأشٞ إجشاء إججبسٛ٘ ٚ ٗ١ رشجٚ ش١ إرا دػذ اٌحبجخ أْ ألذَ فٚ ٟسرٛ ٘ زا اٌطٍت أْ ألذَ طٟثخ فٍٛ اٌّطٟبٔبر١ أْ ألذَ ث:ٍٝافك ػٚ أٚ ٟر٢ ػٍُ ثبٍٝ ػٟٕٔإ
.شح١ اٌزأشٟ إرا ٌضَ األِش ثغشع لشاس ِٕح،بِٕٙ ي اٌشٕجٓ ٌٍزحمكٚخ ثذ١ٕب ٌٍسٍطبد اٌّؼّٙ٠زُ رمذ١ سٟسرٛ طٚ ٟ ثظّبرٚ شح١ ؽٍت اٌزأشٟخ اٌّثجزخ ف١ اٌشخظٟبٔبر١ وبفخ ثٚ ،ٟث
ٍٝ ػ1ٓي اٌشٕجٚبٔبد د١ب ػّٓ لبػذح ثٙ١ٍي ػٛشح ثؼذ اٌحظ١ ِذّ فزشح اٌزأشٚ إثطبي أٚاء ثبٌشفغ أٛشح س١ي ؽٍت اٌزأشٛ وزٌه اٌمشاس اٌّزخز قٚ ِبدٍٛٓ ٘زٖ اٌّؼ٠ رخضٚ زُ إدساج٠ ٚ
يٚ دٟء فٛ اٌٍجٚ جشحٌٙ ِٓ لجً سٍطبد اٚ ٓي اٌشٕجٚخ ٌذ١د اٌخبسجٚشح ػٕذ ٔمطخ اٌحذ١َ ٌٍزحمك ِٓ اٌزأ شٚب ػٕذ اٌٍضٙ١ٍخ ِٓ اإلؽالع ػ١ٕ رزّىٓ اٌسٍطبد اٌّؼٝاد قزِٕٛذاس خّس س
ْٛزّزؼ٠ اٚدٛؼ٠ ٌُ ٚؽ أُٚ ٘زٖ اٌششٙ١ٍٓ ال رٕطجك ػ٠ذ ٘ؤالء اٌز٠ي اٌشٕجٓ ِٓ أجً رحذٚ دٟخ داخً أساػ١ٔٛٔسح لبٛ اإللبِخ ثظٚ اجذٛ اٌزٚ ي اٌجالدٛؽ دخٚاٌشٕجٓ ٌٍزأوذ ِٓ اوزّبي شش
وزٌه سٍطبدٚ ٓي اٌشٕجٚ دٟخ ف١ٕف رزّىٓ اٌسٍطبد اٌّؼٛف ِحذدح سٚ ظشٟ ف.بَ ثذساسخ ٘زٖ اٌطٍجبد١خ ثؼذ اٌم١ٌٛذ اٌّسئ٠ رحذٚ ءٛ ِٓ أجً دساسخ ؽٍجبد اٌٍجٚؽ أٚزٖ اٌ ششٙث
ٖخ اٌّخزظخ ثبٌزؼبًِ ِغ ٘زٙب فئْ اٌج١ٔ ثبٌٕسجخ ألسجبٚ .ٜشح األخش١ اٌجشائُ اٌخطٚخ أ١ ػٓ اٌجشائُ اإلس٘بثٞ اٌزحشٚ اوزشبف أٚبٔبد ِٓ أجً رجٕت أ١ ٘زٖ اٌجٍٝي ِٓ اإلؽالع ػٛثٚسٛ١ٌا
.ٗشح ث١ُ ؽٍت اٌزأش٠ رُ رمذٞ اٌزٍٟ اٌّىزت اٌمٕظٟ٘ بٔبد١اٌج
ٟ اٌحك فٌٟ وزٌهٚ ُٙ أسسٍزٌٟخ اٌزٚ ِؼشفخ اٌذٚ ٓػخ اٌشٕجّٛي ِجٌٚخ ِٓ دٚخ د٠ أٟشح ف١ي اٌزأشِٛبد قٍٛ ٔظبَ اٌّؼٟب فٙ رُ قفظٟ اٌزٟبٔبر١ ثجٞ ؽٍت إخطبسٟ اٌحك فٌٟ ْأدسن أ
َ ثذساسخٛ رمٟخ اٌزٙسح ِحذدح فئْ اٌجٛ إرا لّذ ثطٍت رٌه ثظ.خ١ٔٛٔش لب١سح غٛب ثظِٙ إرا رُ اسزخذاٟبٔبد اٌخبطخ ث١ إٌغبء اٌجٚ حخ١ش طح١خ إرا وبٔذ غ١ اٌشخظٟبٔبر١ح ث١ؽٍت رظح
خٙ اٌجٚ .بٙ أرؼبًِ ِؼٌٟخ اٌزٚ ٌٍذٍْٟ اٌذاخٛٔب اٌمبٙسّح ث٠ ٟ ثطشق اٌطؼٓ اٌزٚ بٙ إٌغبئٚب أٍٙ٠بَ ثزؼذ١ اٌمٚ خ١ اٌشخظٟبٔبر١ اٌزحمك ِٓ ثٟ فٟخ ِّبسسخ قم١ف١ ثىٟٕف رجٍغٛ سٟؽٍج
َ) سزخزض ثبسزالwww.agpd.es 28111 ٞذ٠سلُ ثش6 ُاْ سلٛ خٟسخٛ شبسع خ،ذ٠ ِمش٘ب ِذسٚ بٔبد١خ اٌج٠خ ٌحّب١ٔوبٌخ األسجبٌٛ اٟ٘ ب١ٔ قبٌخ أسجبٟخ ثبٌّشالجخ (ف١ٕخ اٌّؼ١ٔاألسجب
.خ١بٔبد اٌشخظ١خ اٌج٠زؼٍك ثحّب٠ ّب١ فٞٚثبٌشىب
ٌٟخ اٌشٕجٓ اٌزْٚ دٛٔجت لبّٛػغ ِسبءٌخ ثِٛ ْٛ وّب لذ أو،ٌٟ قخٌّّٕٛشح ا١ إٌغبء اٌزأشٚشح أ١ اٌزأشٍٝي ػٛ ٌٍحظٟ سفغ ؽٍجٟحخ لذ رزسجت ف١ش طح١بٔبد غ١خ ث٠ أدسن رّبِب أْ أٚ
.بٙأرؼبًِ ِؼ
يٛؽ اٌذخٚ فمؾ أقذ ششٛ٘ ٞاص سفشٛ جٍٝشح شٕجٓ ػ١د رأشٛجٚ ْ أٞ لذ رُ إخطبسٚ .بٙ١ٍ قظٍذ ػٟشح اٌز١خ اٌزأش١بء فزشح طالقٙ أزٌٜخ اٌشٕجٓ ٌذٚ دٟذ ثّغبدسح أساػٙ أرؼٚ
ٌٟٛٗ سفغ دخ١ٍزشرت ػ٠ ز اٌشٕجٓ ِّب١خ رٕف١ ِٓ ارفبل1/5 ُ ثأقىبَ اٌّبدح سلِٟ قبٌخ ػذَ اٌزضاٟغ ف٠ٛ اٌّطبٌجخ ثزؼٟشح أٔٗ ِٓ قم١ اٌزأشٍٝ ػٌٟٛ قظٟٕؼ٠ الٚ خ١ثٚسٚ األٌٟألساػ
.خ١ثٚسٚ األٟي ٌألساػٛطٌٛ ػٕذ اٜي اٌشٕجٓ ِشح أخشٚي ٌذٛؽ اٌذخٚ ٌششٞز١زُ اٌزأوذ ِٓ رٕف٠ فٛ سٚ ٘زا،خ١ثٚسٚ األٟاألساػ
Place and date خ٠ اٌزبسٚ ْ اٌّىبSignature
(for minors, signature of parental authority/legal guardian):
16-06-2024, Michigan, USA
)ٟٔٛٔ اٌمبٟطٌٛ اٚٓ أ٠اٌذٌٛغ أقذ ا١لٛ ر،غ (ثبٌٕسجخ ٌٍمظش١لٛاٌز
2 In so far as the VIS is operational ..ٗي ثّٛشح ِبصاي ِؼ١ي اٌزأشِٛبد قٍٛ ٘زا إرا وبْ ٔظبَ اٌّؼ1
1 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.
ُٙا قمّٛبسس٠ ٚ ْٚسبفش٠ ٓ٠ األلبسة)اٌز- األؽفبي-جخٚاٌض/جٚ (اٌضٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ اإلرحبد األٟٕاؽِٛ رحًّ ػالِخ (*) ِٓ لجً أفشاد ػبئٍخٟ األسئٍخ اٌزٍٝزُ اإلجبثخ ػ٠ * ال
.35 ٚ 34 إٌمبؽٍٝ اإلجبثخ ػٚ ٞسش٠ٛ اٌسٌٟٔفذساٛ اإلرحبد اٌىٚخ أ١ثٚسٚخ األ٠ػخ االلزظبدّٛي اٌّجٚ دٚ أٟثٚسٚ االرحبد األٟٕاؽُّٛ ثٙثجذ طٍخ لشاثز٠ ُ ِب٠ُ رمذٙ١ٍ ٌىٓ ػٚ ًخ اٌزٕم٠ قشٟف
