Application for long

iscp r. rnoro
Razltko uladu / Stamp of Embassy or Consulate
?adosto ud6leni dlouhodobdho viza
Te n t o
formul 4I j e z d arm a
Application for long-stay visa
This applicatioa form is free ofchatge
Proflednirllely
For Official Use
Only
DanrmpodCn{:
l\
t.Vi
5.
:l:ffi
"
g*g
' '.:
lil-l:,;
i
:
Mlsto narozeni / Place of birth
lfri r-ir..i,rinti i\li=it:iti
i i i I i I : i I I i i : i i ! I i i i i
-DfkDrtG q Gt-td E I t'' Ll ri
Stit narozeni (k6d) / Country of birth (code)
i...\..:..s.\1..H
:-r:
I i:
t/:
Stritnl obdanstvl pii narozen{ (k6d) / Original nationaliry (nationality at birth) (code)
7.
Soudasnd st{tnI obdanswl (k6d) / Current nationality(ies) (code))
N]!rY€T
1.....i2""" I
r"-,r" i4 f\\
f\t\
DopLluj{cl
DL(LrtlLl Li
dokunenty
l) t t1t-t.-
Platnf pas
Prostledky k pobytu
Doklad o ubytovdni
Doklad o trestni
zachovalosti
domovsk€ho stdtu ($
174 zSkona
d.326/1999 Sb.)
r
Ldkaiskri zpriva ($ 31
odst. 5 pism. b)
zrikona t. 326/1999
t'{
Pozvdni
StH\,:> 1
Dt tti.:-r
Dopravnl
prostiedky
i
\ol-]o,r]{'iFl r{
Zdravotni pojiitEni
Hut!t,,\rt rt: ft i'Ctl t
Doklad powrzujici
17
ridel
1951) / Travel document (1951 Convention)
pobltu
Dalii:
1954) / Travel document (1954 Convention)
Dr-i,lt r:
r.....r......r..1,r...Lr....-..,.:.ij',.........,..*
15. Danrm vystaveDl (ddmmrrrr)
16.
/ Date of issue (ddmmyyyy),v'
1
;>
11
t.
.
\'lt''l
Platnf do (ddmmrrrr) / Validuntil (ddmmyyyy),.)p1-.;rt'.
1-'1
g
ii
p,' t
'
i ,.,'.,,'.'....'...''...
i\ illir..: t:T1 i!
*
i
i
;"i""'i""'i
:'-i"';'i".
)i""":":' ,':' .
:i:A:.L.:l:l-l:r:::
i.,L.,;.,1.1.i..:..;..'....i.:..r.:.....i...,..i...,,;
i
Straaa/ Page
I
17. ]esdile se zdrlujete v jin€ neZ domovsk€ zemi, uvedte opnivnEn{ k n{vratu pro zemi
O-CF
byilliit6.
ro
OA air- [*r;ei,li (-iL,r_gr.cr. i:rri,Ula ,"- r,]Z
[L\,_ti,?,!!:.-.t
Uja-p]i
!tvyour
rr you reslge 11 a coultq
offrer than
country
origip.hawe. you permission to returnlo that
Oc,fvi"ii:,
i".r.r
i':€.c,
.vifti.:- tTtf rt\i?
GLt'-c\g
country?
o1-
Pro
rllednl rldely
For OfficialUse Onlv
:""'i*"/Nortft{ {['.
Druhv{za"
Platn6 od:
(s€
Previous stay iu Czech Republic longer than 3 months
Address for stay on
tle territory
of the Czech Republic
r-*€f-
L L,|.-tt'\"'
De fAlt
t" A t
f1r<-
Kt\
Platndpro:
25. Piedpoklddan{dobapobyru/Visaisrequestedlorft}e\<{"SG{4ts!.Gi'.ri'i\ja'iza"y,
26. Ptedchoz{viza (ud€lend Ceskou republikou v posledn{ch tiech letech) a jejich platnost
-fltfg.[k,14.)./.
: L:T,:
country (code)
I,I:
i.,...:.Y;..:.:
:,.,,.:....,i.....:
Strana/
Page 2
28. Udelpobyft/Purposeofstay
Cfrtt 5 5€ &€Ar
Pro
$tednlrllely
For Official Use Only
rJ
-ir Nt.}
B,€
2e. Datum zamfslencho pfijezdu (ddmmrrrr) / Date of arriv"Jiftr
gr,
30. Datum zamfslendho odjezdu (ddmmrrrr) / Date of deparrure (ddrnpyyyy)
i,..:*.Ar.,i.,,4..,;"::.$:...i_:
31. M{sto
:t i
is:..i*. ffi.i,.rJi.*'..'.i.
na rlzem{ Ceskd
",,,.,.;
:.,..i..--.....:
{.P-l*S:..9.r-.S*gyi*tt'S"._c""_r""..*
t_
/ Meens of
Li/*! -sr
iali if\i Lr'\!.-ii ;( ii ifu;tri l:L: t i /i (i-ti \i
:
Zvouc{ prdvnickd nebo fyzickt osoba / Inviting legal or natural person O"r1 t-e*C
]mdno
a
,e'll-r
c€
-r-T{C
lr\f\ trLlt1 Kigi
pHjmeni osoby / Name and sumame of the person
Ulice / Street
MEsto / Town
PSE
/ ZIP
i?-il-".i{"i;;]
!-:-i*-*i-i-.i.-..:..i.I...1...i
34. Zprisob zaji5tEnl rihrady n{kladri spojenfch s pobyrem
\
Mannerof tundi'gthe stay{.ftt-i S riv F if.- Aru\t 'Lo,l*X} .$t=r ui'
i----:
I "iZ"a"ors6m/Myself C-g N Dii\-{
fyzickd osoba(y) / Host person(s) f\(r
{ A\1,,,....iZvouci
i *--:
i."...,...i2"o".i prdvnickd osoba
/
Host.o-p"tyli
(
f2
Lflr1filt,{-
l1-r
:---'!
i
i
i
!
tivobyt{ po dobu pobyru /
iFinandni hotovost / Cash lV.A
ipt",uu"i
;S"U, (cestovni)/ Traveller's cheques
',
co.orrt
i'r i* Prt i tr{"
*:"g
{o:t *"y
dL\ f\-, u-ft
i'
\t
rfr@f l-
tltr+ti
/\ t
{+f
at LV,rtiar ir,",'t ilo-ru" a t
* ipecify,
e.g. certificate of accommod'ation)
i:::;
g J
r/LCr
5
u. r
riif
,S
!
sC:.u€5rue
. trl
\i
",J
.:'---.i.-..!...''i.-'.''.:....,....'.!'.',''.'...1"-.'""i.
iiii
ii
{:t{
>rtrlcr
A\ 1f 7 t"'t- l ft
r \ )bL f-'t'-4'-{
J
/ valid un-til (ddmrslyly)
t:-pf
!Q
t.st
f ,'
a/nebo zdravotni pojiitEni / Travel and./or healrh insuranc".S€1-{
platn6 do (ddmmrrrr)
L,€\
t r{r
't I
karty / credit cards !( Ae O i t A €
'iorr"tni/other
"
of rlnng.t
tr
rt"lft s I'ir\i: L ft
Lr '{
Dai
-9xt"lltsp.si*5:iF".:l"p"i:.,.*-""*J:.*."""."*Iy"::.:::i).{"9,fr
1
*:"n
(
i rf}
Uvedte odpovidajicf doklady / Presenr corresponding documenration i-L
35. Finandn{ prostledky k
911{f,
e
i..C
_ _ L ::--i-i*ii^|.:::j...
""" ;"""""';" """;" "'i"""" i'
t-'-t t l( -\r'rfl^ C Sr
Strana/ Page 3
,..,i....,, :
Profledn{rllely
ForOftcirl gss go1,
t,
Stdtni obdanstvi manielky (k6d) /Spouse's nationality (code)
f.--,fp
.f
O(:) L,l
Jt t q
37. DEti (pro kaidou osobu musi byt podrina samostarnd iridost) L rra t-t t, trlrZ
children (Applications must be submitted separately for each passport) r€p-- t
f\:r\('cd s r(1
't7- rLj.ri;.irtutAt
i
|
Ay at "ftSA
b.
t""'1""'i""'i""'t""'t"""i""'i""'i
i......i,....i......:......i.....!......i.....;...,.i
d.
ilr
"r"
:""'T""'i
:::i::i:: ""'1"" "':"" ":"'.',.....r
:::::;ii:
Strana/ Page4
1.
Udaje v iidosti musi bjt rypln6ny strojem nebo htlkovfm pismem v desk6m
uvedte ridaje na zvl6itni pfilohu.
1'azyce.
V piipad6 nedostatku mista v piisluiny'ch rubrikdch
t.326/1999Sb.,opobytucizincrina(zemiCeskd
2.Prdvaapovinnosticizincri,spojen6spobytemna(zemiCRlrouupravendzdkonem
republiky a o zm€nE ndkterych z6kont, ve zn6ni pozddjiich piedpisti'
avestanovenlichpiipadech
3.Osobniridajeproudelyiizenipodlezdkonat.32611999Sb.,jsouzpracovdvdnysluiboucizineck6policie,
Ministerswem vnitra v souladu se zdkonem d. 101/2000 Sb., o ochrand osobnich tdajri, ve znEni pozd€jiich pfedpisri.
4.
V souvislosti
s Zddosti o
5. Zavazttji se opustit
dlouhodobd vizum jsem povinen na poi6drini strpdt sejmuti otiskt prstt
fzemi
Cesk6
a
poiizeni obrazovdho zAznamtt.
republiky pied skondenim doby povolen6ho pobytu na fzemi Cesk6 republiky.
6. Byl jsem informovdn o skutetnosti,
ie ud€leni viza je jen jednou z podminek vstupu na rizemi Ceskd republiky. Pouhri skutednost, Ze mi bylo
uddleno vizum, neznamen6, ie mfm pr6vo na n6hradu 5kody, pokud z drivodri nesplndni podminek vstupu a pobycu na uzemi Cesk6
republiky stanovenlich zdkonem d. 326/1999 Sb., mi bude vstup na rizemi Ceskd republiky odepien.
7. Byl jsem
informoviin,
Ze
jsem povinen do 3 pracovnich
dnri
ode dne vstupu na
rizemi ohl6sit
na
policii Ceskd republiky misto pobytu na
rizemi Cesk6 republiky.
8.
Prohlaiuji, ie jsem vSechny vjie uvedend ridal'e poskytl(a) podle svdho nejlepiiho v6domi
1. Details
a svEdomi a
ie jsou sprdvn€
a
ripln6.
in the Application must be completed in block letters in the Czech language. If more space is needed, specify the details in a special
enclosure.
ofaliens connected with their stay on the territory ofthe Czech Republic are governed by Act no. 326/1999 Coll.,
regulating Residence of Alliens in the Territory of the Czech Republic and on changes of some acts, as amended.
2. Rights and duties
for the purpose ofproceedings pursuant to Act no. 32611999 Coll. are processed by the foreign police service and by
of Interior in specified cases pursuant to Act no. 101/2000 Coll. regulating personal data protection as amended.
Ministry
3. Personal details
4.
In relation to the Application for
a
long-term visa, I am obliged to suffer fingerprinting and taking ofvisual image on request.
5. I hereby undertake to leave the Czech Republic before the termination of my permitted stay on the territory of the Czech Republic.
6. I have been informed about the fact that granting a visa is only one of the conditions for entering the Czech Republic. The mere fact that I
have been granted a visa does not mean that I am entitled to damages in case that I am prevented from entering the Czech Republic based on
my failure to meet conditions for entry and stay in the Czech Republic specified in Act no. 32617999 ColI.
7.
I have been informed that I am obliged to report the place of stay in the Czech Republic to the Czech Police within
3 business days
following
my€ntry. I
8.
I h{reby represent that I have provided all the above specified details according to my true and free will and that they are complete and
tf
codrect.
adatun: ar,- 1
anddate: lC!-.
\C
_._\,\
({\-tt-]
Podpis ladatele ( u nezletiljch podpis zrikonndho z:istupce):
Applicant's Signature (for minors, signature of custodian/guardian):
Flr-r
?+
Misto pro nalepeni kontroini d:isti vfzovdho Stitku
Podpis pracovnika vyddvajiciho vizum
Strana/ Page 5