Temporary Stay PDF

Naziv tijela kojemu se zahtjev podnosi OBRAZAC 1a
Form 1a
Name of the authority to which the application is submitted
PRIJAMNI PEAT
STAMP OF RECEIPT
ZA HTJE V Z A I Z D A V A N J E :
APP LI CATIO N F O R I S S U A NCE OF :
odobrenja za privremeni boravak
Approval for temporary stay
odobrenja za stalni boravak
Approval for permanent stay
poslovne dozvole
Business permits
prvo izdavanje produenje
First issuance Extension
1. Prezime:
Surname:
2. Bive, odnosno roeno prezime:
Maiden surname (for married women):
3. Ime:
Given name(s):
4. Spol: muko ensko
Sex Male Female
5. Ime roditelja: otac:
Given names of parents: Father:
majka:
Mother:
6. Datum, mjesto i drava roenja:
Date, place and country of birth:
7. Dravljanstvo:
Nationality:
8. Brano stanje:
Marital status:
neoenjen / neudana oenjen / udana udovac / udovica rastavljen
single married widow(er) divorced
9. Adresa u Republici Hrvatskoj:
Address in the Republic of Croatia:
10. Adresa u inozemstvu:
Addres in a foreign country:
11. Svrha boravka:
Purpose of stay:
12. Podaci o osobi na temelju ijeg statusa u Republici Hrvatskoj se trai odobrenje boravka:
Data about the person on the basis of whose status in the Republic of Croatia residence permit is requested:
a) Prezime, ime:
Surname and given name(s):
b) Datum, mjesto i drava roenja:
Date, place and country of birth:
c) Dravljanstvo:
Nationality:
d) Status lana obitelji:
Status of the family member:
obiteljska zajednica datum sklapanja braka:
conjugal community Date when marriage was contracted:
rodbinski odnosi:
family relationships:
e) Podaci iz putovnice hrvatskog dravljanina/stranca koji ima reguliran status u Republici Hrvatskoj:
Data from the passport of the Croatian/foreign citizen who has a regulated status in the Republic of Croatia:
Broj putovnice:
Passport number:
Datum izdavanja:
Date of issue:
Vrijedi do:
Valid until:
f) Adresa:
Address:
Prijavljen od:
Registered since:
g) U sluaju nepostojanja zajednike adrese stanovanja, molimo navedite razloge:
In case there is no joint residential address, please specify the reasons:
13. Putna isprava podnositelja zahtjeva:

Travel document of the applicant is required by:
Tijelo koje je izdalo putnu ispravu:
The authority that has issued the travel document:
Mjesto i datum izdavanja:
Place and date of issue:
Broj: Isprava vrijedi do:
Number: Document valid until:
14. Rok vaenja zadnjeg izdanog:
Period of validity of the last approval issued:
odobrenja za privremeni boravak
approval for temporary stay
poslovne dozvole
business permit
odobrenje se izdaje prvi put
approval is issued for the first time
15. Rok vaenja izdane osobne iskaznice za stranca:
Period of validity of the identity card for foreigners issued:
na odobrenom privremenom boravku
for the temporary stay approved
na odobrenom stalnom boravku
for the permanent stay approved
s odobrenom poslovnom dozvolom
for the business permit approved
16. Ulazak u Republiku Hrvatsku:
Entry into Republic of Croatia:
a) obveza posjedovanja vize: da ne
obligation to possess a visa: Yes No
b) viza broj:
visa number:
Vrijedi do: Tijelo koje je vizu izdalo:
Valid until: Issued by the authority:
17. Podatak o posjedovanju sredstava za uzdravanje:
Information about possessing funds for subsistence:
A. Osobni prihodi iz:
Personal income from:
nesamostalne djelatnosti
Unindependent activities
Visina prihoda:
Amount of income:
Radna dozvola izdana dana: Broj:
Work permit issued on: Number:
Godinja kvota: da ne
Yearly quota: Yes No
Vrijedi do:
Valid until:
Ime i adresa poslodavca:
Name and address of the employer:
B. Samostalne djelatnosti:
Independent activities:
C. Sredstva za uzdravanje koja se dobivaju od tree osobe:
Funds for subsistence received from third persons:
Ime i adresa stanovanja:
Name and address of the person:
D. Podatak o drugim financijskim sredstvima za ivot:

Information about other financial resources for living:
18. Podatak o zdravstvenom osiguranju:
Information about health insurance:
19. Zakonske obveze uzdravanja druge osobe:
Legal obligations for supporting other person(s):
20. Dokaz o osiguranom stanovanju:
Proof of secured dwelling:
21. Stupanj naobrazbe:
Level of education:
22. Predvieno trajanje boravka: od: do:
Anticipated period of stay: From: to:
23. Razlozi podnoenja zahtjeva:
Reasons for submitting the application:
24. Zavrna izjava:

Final statement:
a) Ovim potvrujem da su svi podaci navedeni u tokama 1. - 23. potpuni, te da odgovaraju istini i podacima
u priloenim dokumentima. Potvrde koje su na drugom jeziku priloene su u hrvatskom prijevodu.
Hereby I confirm that all information given under Items 1. - 23. are complete, that they are true and correspond
to the data contained in the documents attached. Certificates in another language are attached in the Croatian
translation.
b) Ovim se obvezujem da u svaku promjenu osobnih podataka prije ulaska u Republiku Hrvatsku,
putem diplomatskih misija, odnosno konzularnih ureda Republike Hrvatske, dostaviti hrvatskim
nadlenim tijelima.
Hereby I undertake, that I will communicate any change of my personal data to the Croatian competent
authorities through diplomatic missions or consular offices of the Republic of Croatia before entering the
Republic of Croatia.
c) Primam na znanje da su moji osobni podaci u svrhu sastavljanja zapisnika i arhiviranja informatiki obraeni.
I take note that my personal data are computer processed for the purpose of drawing up the minutes and
of filing.
d) Primam na znanje da moj zahtjev zbog nepotpunih i netonih podataka, kao i zbog neispunjavanja
toke 24. b i 24. c moe biti odbijen.
I take note that my application may be refused on account of incomplete and inaccurate data as well as
noncompliance with the Subitems 24.b) and 24.c).
U , dana
In Date:
Potpis podnositelja zahtjeva

Signature of the applicant:
fotografija
30 x 35 mm
Photo
Potpis slubene osobe:
Signature of the official person:
Popunjava slubena osoba kojoj je zahtjev podnesen:

To be filled out by the official person to whom the application was submitted:
Ishod postupka:
Result of the procedure:
Broj rjeenja i vrsta odobrenja:
Number of decision and type of approval:
Datum izdavanja odobrenja:
Date when the approval was issued:
Vrijedi do:
Valid until:
Potpis slubene osobe:

Signature of the official person:

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Naziv tijela kojemu se zahtjev podnosi OBRAZAC 1a

13. Putna isprava podnositelja zahtjeva:

D. Podatak o drugim financijskim sredstvima za ivot:

24. Zavrna izjava:

Potpis podnositelja zahtjeva

Popunjava slubena osoba kojoj je zahtjev podnesen:

Potpis slubene osobe:

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