DA/DB/Dc

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CONSULATUL GENERAL AL ROMANIEI LA ISTANBUL
Operator de date cu caracter personal notificat sub numerul 5285
I
FOTOGRAFIE
3x4CM
VEsiKt\UK
FOTO(IRAF
Solicitare de viza
Vize Basvuru Formu
Application for Visa
TIP DE VIZA I
Formular gratuit /
1.
ViZE TURU I TYPE
OF ViSA:
A, 8, C
Bu form ucretsizdir / This application form is free
Numele
Soyadr
Surname(s) (family name(s))
2.
Numele la nastere
Onceki soyadr veya krzhk soyadi
f--::---=S:.::u:.:.:rn..:.::a::.:..m:.:ce::.J~(~!sL)a=:.:t:...::b:..::irtc::h-'-i3. Prenume
Adl
First names (Qiven names)
1-4-c-.-D:..:a.:.:t:'O'a.:.:n=a:.:..~t:=e-=-ri-"i
=':"~:":=":"=-=.L--------l--::5'-.
Dogum tarihi
__
,__
Cheie:,,,,,,"""",
-------l
Cerere: ROM" """."
I __
ID-number:::-
Date of birth
I-:-
6.
-l-
-l
f--~~=-~:::...::::=~~.::::.:.:.~--------l----------___..c__----___l
7.
Cetatenla prezenta / Tabiyetl
8.
I Current
nationality(ies)
Cetatenia la nastere 'Ilk tabiyeti ,
Original nationality (nationality at birth):
I-g=-.-S-c-e-x-u-I-'---:
Cin-s-iy-e-t-'-S-e-x-:
----------f----:1c=O-.-S-t-at-u-t
status:
o Barbatesc'
o Ferneiesc ,' Kadm
o Separat
Tipul de viza :
I Separated
1
o Pasaport
diplomatic'
o Pasaport
turistic , Turistik
o Passport
de serviciu , Hizmet
Diplomatik
'Type
pasaportu
pasaportu
o Altele
de marinar , Gemici
pasaportu
(specitlcatl) , Diger(belirtiniz)
D1/D2/DM
/ Di(Jer , Other
Valabila de la:
Numele mamei
Anne adt
Mother's name
of passport:
la:
, Diplomatic passport
",
Viza:
, Service passport
o Document de catatorie pentru refugiali , MUiteci seyahat belgesi
o Pasaport pentru straini / Yabancilar pasaportu , Alien's passport
o Carne!
Nr. de intrari:
Dull Widow(er)
, National passport
pasaportu
DA/DB/Dc
, Divorced
12.
turu
o
, Married
, Aynlml§
o Vaduv(a)'
11. Numele tatalui
saba adt
Father's name
13. Document de calatorie J Pasaport
.
Documente doveditoare:
0 Pasaport valabil
0 Mijloace financiare
0 lnvitalie
0 Mijloace de transport
0
Bile! de calatorie
0 Asigurare
de sanatats
0 Dovada asigurarii conditiilor de
cazare
Exceptii: (se va camp/eta in functie
, Bekar J Single
o Divortat , Bo!?anml~
o Altele
,
o.UG,194/2002))
o casatorlt I Evli
, Female
"" ".
de dacumente/e prezentate de
'-ci'-vC:Me--:d-e-ni::-Ch-a'-I-=-i
'-M-a-rit-a-,-I-----l SOlicitant, in contormitsie cu ari,40 din
il-':-::-
o Celibatar
Erkek , Male
""".
Document
procesat de:
-C-N-P::-:-':-:V-at-a-n-'d::-a-ll-=-hk'----s"--ic-il'-n-u-n--,a-r-a-s-I
-, -----1
---:---:_--= __
,_____
gun
ay
yll
-'D=---..;:-....:.M=-=-- Y-'-- __
Locul ~i tara nasterii
.•..
Dogum yeri ve Ulkesi
Place and country of birth
.... ,, ..... ,.... ,.. ,.
'Travel
document
I Seaman's passport
, Other travel document (please specify):
D
Refuzata
D
Acordata
.
; 14. Nr. de passport I Pasaport Numarasl
I Number of passport:
17.
la I Ge<;erlilik
de /Veren
tarihi
I Valid until:
116.
Data emiterii
18.
Oaca av?!i do.miciJiulin ~!t stat dscat eel de oriqine, va este permis sa va relntoarceti in ~~est stat I Ba$ka iilkede ikamet edlvorsaruz
donmeniz m£isaade edltlyor mu? Ilf you reside In a country other than your country of onqm, are you allowed to return to that country?
I
1
I Verili~
tarihi
I Date
of issue:
Emis
makam
/ Issued by:
0 (jlkeye
o Nu I HaYlr I No
o Da (numarul ~i valabilitatea permisiunii) I Evet (saYlsl ve sOres;) I Yes, (number and validity):
19.
Functia ocupata in prezent 1 Mevcut goreviniz 1 Current occupation:
20.
Angajatorul, adresa acestuia si nr. de tel. Pentru elevi ~i studenti, denumirea ~i adresa institutiei de invatamant / i~verenin adr, adresi ve telefonu.
Ogrenciler icin okulun adr ve adresi I Employer and employer's address and telephone number. For students, name and address of school:
21.
22.
Destinatia
principala I Esas gideceginiz yer I Main destination:
Nr. de intrari solicitate I istenilen giri$ saYlsl I No. of entries
requested:
I
I 0 Unica intrare I Tek 9iri$1 Single entry
23.
Durata sederf / Kalma sOresi 1 Duration of stay:
.............................. zile I gOn i<;indir / days.
o Doua intrari I iki giri$ / Two entries
o Multiple intrari / Coklu giri!j I Multiple entries
.
5. Veiabilpana
Viza solicitata pt. Iistenilen
.
....................
,I
vize 1 Visa is requested for:
.... I!;tn d'Ir I d ays.
ZI'1e I uun
24.
Aile vize emise in ultimii 3 ani $i valabilitatea lor I Son 3 Ylldaaldlglnlz
and their period of validity:
25.
In cazul unei vize de tranzit, detineti permisiunea de a caliitori in statui de destina\ie? I Transit durumunda esas gitmek istediginiz
seyahatetme izniniz var rm? Iin the case of transit, do you have an entry permlt for the final country of destination?
ba§ka vizeler ve sOreleri I Other visas (issued during the past three years)
iilkeye
I
I 0 Nu I Hayir { No
I0
Da, valabila pana la I Evet ve tarihine kadar geceriidir I Yes. valid until:
.
Ernisa de I Veren makam Iissuin
26 .•
27.
authorit:
.
$ederi anterioare in Romania I Romanya'ya onceki kalislariniz I Previous stays in Romania:
Scopul sederii in Romania I Seyahat amaer! Purpose of travel;
I 0 Misiune
(C/M) I Resmi I Official
I 0 Afaceri (CIA) { i$/
Business
I 0 Transport (CITR) / Nakliyat I Transportation
I 0 Turism (CITU) I Turizm 1 Tourism _
o Vizita (CNV) I Akraba veya dost
ziyareti I Visit to Family or Friends
o
Aclivila\i culturale, :;;tiintifice, umanitare, tratament medical de scurta durata care nu contravin legilor rornane (C/ZA) I Romanya yasalarma aykir
olmayan kisa surett kOitur, bilimsel, Insani ve ttbbi tedaviler I Shortcultural, scientific, humanitary, medical treatment activities in accordance whit!
i romanian law.
I
o Activitati sportive (C/SP) 1 Spor faaliyetleri
o Tranzit aeroportuar I Hava alam transit
I Sport
I Airport transit
o
Tranzit I Transit I Transit
28. • Data sosirii I Giri§ tarihi
I Date of arrival:
29. * Data plecarii I Clkl$
tarihi ! Date of departure:
I
gOn
Y
ay
o
YII
M
Y
3U. ',Punctul de intrare. sau traseul de transit' Glrll$ kapist ya da transit rotasr '
Border of first entry or transit route:
31. * MiJlocde transport'
Ulaflm aract , Means of transport:
i
"
32,.• Denumirea firmei romans de contact ~i a persoanei responsabile in cadrul acesteia. In absente, denumirea hotelului sau adresa ternporara in
~ Romania' Romanya'daki irtibat slrketlnln adt ve yetkillslnln adr, Yoklugunda, kalacaqunz otelln adl veya gec;:iciolarak kalacaguuz adres 1
Name of host or company in Romania and contact person in host company. If not applicable, give name of hotel or temporary address in Romania:
33.
Nume 1 Adl ! Name:
Tel. si fax! Tel. ve faks! Phone and fax no.:
Adresa completa ! AC;lkadresi ! Full address:
e-mail! e-posta adresi 1 e-mail address:
* Cine suporta cheltuielile de deplasare ~i de sedere in Romania? ! Romanya'ya gidi!j ve kahs masraftarrm kim karsrhyor ? ! Who is paying for
your cost of travelling and for your costs of living during your stay?
o Subsemnatul! Kendim ! Myself
o Persoana fizica romana ' Romen gercek kilji' Romanian natural person (s)
o Persoana juridica rornana (numiti cine ~i anexatl documente doveditoare) , Roman tilzel
I
I
I
ki§i (adim belirtiniz ve ilgili belgeleri ekleyiniz I Legal
person! Host company (State who and how and present corresponding documentati1n)
34. * Modalitati de Intretinere in Romania / Romanya'da gec;:inmearaclari / Meanslof support during your stay:
o Cash I Nakit para
o Cecuri de calatorie , Seyahat
~ekleri , Travellers' cheques
o Car1ide credit 1 Kredi kartlan / Credit cards
o Cazare platita ! bnceden odenmls konaklama
o Allele I Diger (belirtin)
, Prepaid accommodation
/ Other:
o Asigurare medicala valabila pana la / Tarihine
kadar gec;:erlisaghk slqortasr ' Travel and/or health insurance. Valid until:
.....................................................................
35.
Numele sojulut (sotiel) 1 Eljinizin soyadi / Spouse's surname:
37.
Prenumele sojului (sotiei) /
E~inizin ad: / Spouse's first name:
38.
36.
Numele la nastere al sojului (sojiei) / Eljinizin ilk soyadr (klzllk soyadi) /
Spouse's surname at birth:
139.
Data de nasters a sojului (sojiei)' Eljinizin
dogum tarihi / Spouse's date of birth:
-'- ,
gun
D
ay
M
Locul de nastere al sotului (sotiei) I E~inizin dogum
yeri / Spouse's place of birth:
YII
Y
40. Datele personale ale cetateanului roman in tntrejinerea canna va gasiti. Rubrica de completat doar de catre cei afiati in intretinerea unui cetatean
roman / Size bakmakla yukumlu Romanya vatandasmrn sahst bilgileri. Bu hane sadece bir Romanya vatandasmm bakimmda olanlar
tarafmdan doldurulur / Personal data of the Romanian citizen who supports on. This question should be answered only by family members of
Romanian citizens.
Nume I Soyadl / Name:
Prenume / Adl / First Name:
Nr. de passport / Pasaport Numarasl / Number of passport:
Data nasteril / Dogum tarihi / Date of Birth I:
gun
----I
ay
D
M
/
yll
Y
Legatura famltiala I Akraballk bag I / Family relationship:
~1.
Daca aveti aile rude in Romania? / Romanya'da baska akrabalannrz var mi? / Do you have any other relatives in Romania?:
142.
Am luat la cunostinta urmatoarele: toate datele personale cu privire la subsemnatul(a) care apar in prezentul formular vor fi puse la olspozttla
autorltatnor romans competente $i procesate de catre acestea, dupa caz. in scopul luarll unei decizii cu privire la prezenta solicitare de viza. Aceste
date pot fi introduse $i stocate in bazele de date accesibile autoritajilor romane competente.
Urmare solicitaril exprese a subsemnatului. autoritatile eonsulare menite sa proeeseze prezenta solieitare ma vor informa cu privire la la modalitatea in
care lmi pot exercita dreptul de a verifica dalele personale furnlzate, de a dispune modificarea sau lndepartarea lor, daca se dovedesc incorecte, in
conformitate cu prevederile legislatiei 1nvigoare 1nRomania.
Declar ca, dupa ~tiinta mea, taate datele furnizate sunt corecte ~i complete.
Declar ca am cuno~tinla de faptul ca orice date false furnizate conduc la respingerea prezentei solicitari sau la anularea vizei emise In baza acestora si pot
>
duce la declansarea urmarirf mele penale in conformitate cu leqea rornana. Ma obliq sa oarasesc teritoriul Rornaniei la expirarea vizei ce rni-a fast
I
acordata.
I
!A.mfost informal ca detinerea vizei nu reprezinta decAt una dlntre conditiile de indeplinit pentru intrarea in Romania. Simpla eliberare a vizei nu presupune
faptul cs sunt indreptslit(s) la primirea unor compensatii daca nu indeplinesc conditiile pr~vazute la Capitolul II (Dlspozltil generale privind irJrarea,
sederea ~j ie~irea strainilor) al OUG 19.4/2002 !1ifm; este refuzata intrarea in Romania. tndeplinirea condiliilor de intrare va fi sup usa vei~ficarii la
momentul intrarii pe leritoriul Romaniei.
Sunt de acord cu prelucrarea datelor prezentate In confonnltate cu Legea 677/2001
sbu form i4~inde yer alan ve kendime ait olan tOm sanst bllgller Romanya IIglli makamlarma verilecegl ve duruma gore vize basvurusu
konusunda bir karar ahnmak (izere i~leme konulacag, konusunda bilgilendirildim. Bu bilgiler ilgili Romen makamlarmm ula$abilecegi bilgi
arslvlne aktanhp muhafaza edilebilir.
I'
Ozel istegim ilzerine i!?bu basvuruyu i!?lemekle gorevli konsolosluk makamlan verdigim !jahsi bilgilerin kontrol edebilme, yanlt!j olduklarr
taktirde onlan degi!jtirme veya silme hakknm yuriirliikte alan Romanya yasa,lar," hukumleri geregince nasrl kullanabilecegimi bilgilendirir.
sbu formda yer alan tum bilgiler bildigim kadanyta dogru ve eksiksiz olarak verilldigini beyan ederim.
tyerilen herhangi sahte bilgi basvunmun reddedilmesine veya bu bilgilere dayamlarak verUen vizenin iptaline vesile olup Romanya yasalarma
gore cezai takip ba~lat"abileceginden bilgim oldugunu beyan ederim. Veriten vlzenin bitiminde Romanya'dan S;lkacaglml taahhilt ederim.
r.tizenin verilmesi Romanya'ya giri, sartlanndan sadece birini te,kil ettigi konusunda bilgllendirildim. 194/2002 SaYI" tarihli Romanya HOkOmet
Kararnamesi'nin
IInci BolOmOnde (Yabancllarm giri~i, kalmast ve c.~masl hakkmda genel hOkumler) yer alan sartlan yerlne
getirmedigimden illkeye giri$im kabul edilmezse, sadece vizenin verilmesi tazminat isteme hakk] vermez. Giri$ sarttarm verine getirilip
getiritmedigi Romanya'ya giri~ yaplldlgl zaman denetlenir.
677/2001 saYl1tvasa geregince verilen bilgilerln 1~lenmesini kabul ediyorum
I am aware of and consent to the following: any personal data concerning me which appear on this visa application form will be released myself to the
relevant authorities in Romania and processed by those authorities, if necessary, for the purposes of a decision on my visa application. Such data
,
may be input into, and stored in, databases accessible to the relevant authorities in Romania.
t my express request, the consular authority processing my application will inform me of the manner in which I may exercise my right 10 check the
personal data concerning me and have them altered or deleted, in particular, should they be inaccurate, in accordance with the national law of the
state concerned.
I declare that to the best of my knowledge all information provided is correct and complete.
.
~
I am aware thai any false slatements 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 Romanian law which deals with the application. I undertake to leave the territory of Romania upon 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 Schengen 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 Ch.apter II
(General provisions regarding entry, stay and exit of aliens) of GEO nO.194/2002 and am thus refused entry. The prerequisites for entry will be
checked again upon entry into the territory of Romania.
I aqree with the processing of data presented in according with Law no. 677/2001
43. Adresa de domiciliu a solicitantului / Basvuranm ikamet adresi I Applicant's home address:
44. Numar de tel. I Telefonu I Phone no.:
45.
Data la (Iocul ~i data) I Ba§vurunun yeri ve tarihi 1
Place and date:
46.
semnatura (pentru minori, semnatura reprezentantului legal) I imza (re~it olmayanlar
i~in yasal vekili) / Signature (for minors, signature of custodian/quardian):
--,--,----:---gOn ay
ytl
D
M
y
, 47.
!
j
!
!
•
•
•
Rubricile insotite de semnul *, nu trebuie completate de membrii familiei resortisantilor UE sau SEE (sot, sotie, copil sau ascendant
dependent).
Membrii familiei resortisantilor UE sau SEE trebuie sa prezinte documentele care dovedesc relatia de rudenie.
(* )Ylldlzh i§aretli haneler AB veya SEE vatandaslarrrun aile uyelerinin (es, cocuk veya bakrnakla yukumlU
oldugu anne,baba) tarafmdan doldurufmayacaktrr.
AB veya SEE vatandaslanrnn
aile uyeleri akrabahk baghhgl lspatryrci belgeleri ibraz etmeleri
gerekmektedir.
The question marked with *, do not have to be answered by family members of EU or EEA citizens (spouse, child or dependent ascendant).
Family members of UE or EEA citizens have to present documents to prove this relationship.