Fill and Sign the University Request Form

Consulate General of Italy – Los Angeles PHOTOGRAPH National (D) visa application form This form is free of charge 1. Surname (Family name)/ (x) ........................................... For official use only 2. Surname at birth (Former family name(s)) / (x) Data della domanda: 3. First name(s) / (x) 4. Date of birth (day-month-year) 5. Place of birth 7. Current nationality 6. Country of birth 8. Sex: Nationality at birth, if different 9. Marital status: Male Female. Single Separated Widow(er) Other (please specify) Married Divorced Numero della domanda di visto: Domanda presentata presso: Ambasciata/Consolato Centro comune Fornitore di servizi Intermediario commerciale Altro Nome: 10. For minors: surname, first name, address (if different from the applicant’s) and nationality of parental authority/legal guardian: Responsabile della pratica: Nome di chi ha ricevuto la pratica allo sportello: 11. National identity number, where applicable: 12. Type of travel document: Ordinary passport Service passport. Special passport Other travel document (please specify): 13. Numer of travel document Diplomatic passport Official passport 14. Date of issue.(day-monthyr) Documenti giustificativi: 15. Valid until (day-month-yr) 16. Issued by Documento di viaggio Mezzi di sussistenza Invito Mezzi di trasporto Assicurazione sanitaria di viaggio Altro Telephone number(s) 17. Appplicant’s home address and e-mail address ...................................... Decisione relativa al visto: 18. Are you residing in a country other than the country of your current nationality: No Yes. Residence permit or equivalent:.....................: ………………N.………………………. Valid until ………………….. 19. Current occupation Rifiutato Rifiutato per segnalazione SIS non cancellabile. Pratica Sospesa Rilasciato Tipo di visto: D 20. Employer, employer’s address and telephone number. For students, name and address of educational institution. Valido: dal ………………………….. 21. Purpose of travel: al……………………………. Joining family member/ Accompanying family member Numero di ingressi: Religious activity Sport Mission Diplomatic Medical reasons Study Adoption Subordinate work Autonomous work Other (specify)/.....................................……………………………. 1 2 Multipli (x) Provide the information as indicated in the travel document. 1 22. City of destination 23. Schengen country of first entry 24. Number of entries requested: One Two Multiple. 25. Duration of stay. Indicate the number of days (max. 365 days) 26. Schengen visas issued in the past three years: None Yes. Date(s) of validity: from ...…………………………….. to.. ………………………………. … 27. Fingerprints previously taken for a Schengen visa application: No Yes. Indicate date if known:………………………………………………. 28. Number of the Nullaosta issued for a Joining family member visa/Accompanying family member visa/ Subordinate work visa (only when required by the regulations governing the type of visa requested)………………. Issued by the SUI of the city of ……………………………………. Valid from ………………….until……………….. 29. Intended date of arrival in the Schengen area 30. Intended date of departure from the Schengen area (only for visas valid from 91days to 364 days) 31. Name of the person who requested the family reunion visa, or the name of the employer. Indicate your address in Italy, if it is visa for Adoption, Religious Activities, Medical Reasons, Sport, Study, Mission. Address and e-mail address of the person(s) who requested the family reunion visa, or the name of the employer. Telephone number and fax number of the person(s) who requested the family reunion visa, or the name of the employer. 32. Name and address of the inviting company/ organization. Telephone number and fax number of the company/ organization.. Name, address, telephone number, fax number and e-mail address of the contact person of the company/ organization. 33. The applicant’s expenses for travel and stay are the responsibility of: the applicant. Means of support: Cash Traveller's cheques Credit cards Prepaid accomodation Prepaid transportation Other (specify)…………………………. INFORMATION NOT NECESSARY FOR THE FOLLOWING VISAS: Joining Family Member, Accompanying Family Member, Subordinate Work,Autonomous Work, Mission, Diplomatic, Adoption. of the sponsor (host, company, organization), specify:…………………………………………… ………………………………………………….. referred to in field n. 31 or 32. other (specify)..........................:………………… Means of support: Cash Accommodation provided All expenses covered during the stay.. Prepaid transportation Other (specify) ……………………………….. 2 34. Personal data of the family member who is a citizent of the EU, EEA or CH: Surname (family name). Date of birth First name(s) Nationality Number of travel document or ID card 35. Family relationship with a EU, EEA or CH citizen: spouse son/daughter other direct ascendant –grandchild dependent ascendant 36. Place 37. Signature (Signature of parent or legal guardian if applicant is a minor) Date ............................................................................................................................................................................. ........................................................................................................................................... I am aware that the handling visa fee is not refunded if the visa is refused. I am aware of and consent to the following: that the collection of the data required by this application, the taking of my photograph and, if applicable, the taking of my fingerprints are mandatory for the examination of the visa application, and that the personal data concerning me which appears on the visa application form, as well as my fingerprints and my photograph will be supplied to the relevant Italian authorities and processed by those authorities for the purpose of a decision on my visa application. Such data, as well data concerning the decision taken on my application or a decision whether to annul or revoke an issued visa will be entered into and stored in the visa information system of the Italian Embassy/Consulate and of the Italian Ministry of Foreign Affaire. Such data will be accessible to the national authorities responsible for visas. Furthermore, such data will be accessible to the Schengen authorities competent for carrying out checks on visas at external borders, to the immigration and asylum authorities of the Member States (for the purpose of verifying whether the conditions for the legal entry into, the stay and residence on the territory of the Member States are fulfilled, of identifying persons who do not or no longer fulfil these conditions), to the authorities of the Member States responsible for examining of an asylum application. Under certain conditions the data will also 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. I am aware that I have the right to obtain notification of the data relating to me recorded in the visa information system, and the right to request that inaccurate data relating to me be corrected and that data relating to me processed unlawfully be deleted. At myrequest, the authority examining my application will inform me of the manner in which I may exercise my right to verify my personal data, and have them corrected or deleted, including the related remedies according to the national legislation. The responsible national authority is the “Garante per la Protezione dei Dati Personali”. I declare that all the data provided by me are complete and correct. I am aware that 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 Italian Representative (article 331 c.p.p.). The mere fact that a visa has been granted 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 n. 562/2006 (Schengen Borders Code) and of Article 4 of Italian Law 286/98 and for said reasons I will be refused entry. 3 ANNOTAZIONI ( . riservato all’Ufficio) ........................................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................. 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Place Signature (Signature of parent or legal guardian if applicant is a minor) Date 4