Application-Form - Italy 1

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Consulate General of Italy of Italy

Kolkata
Application for Schengen Visa

(This application form is free)
Family members of EU, EEA or CH citizens shall not fill in fields no.21, 22, 30, 31 and 32 (marked with *).
Fields 1 3 shall be filled in in accordance with the data in the travel document.
1. Surname (Family name): FOR OFFICIAL USE ONLY
SHERCHAN Date of application:

2. Surname at birth (Former family name(s)):
3. First name(s) (Given name(s)): Application number:
RISHI KUMAR
4. Date of birth (day month year): 5. Place of birth: 7. Current nationality: Application lodged at:
29/06/1976 □ Embassy/consulate
LUMBINI NEPALESE □ Service provider
□ Commercial intermediary
6. Country of birth: 8. Nationality at birth,
NEPAL if different:
□ Border (Name):
…………………………………………
9. Other nationalities: □ Other:
8. Sex: 9. Civil status:

□ Male □ Female □ Single □ Married □ Registered Partnership □ Separated □ Divorced □
Widow(er) □ Other (please specify):
10. Parental authority (in case of minors) / legal guardian (surname, first name, address, if different from File handled by:
applicant’s, telephone no, e mail address, and nationality):
11. National identity number, where applicable: Supporting documents:

133 □ Travel document
12. Type of travel document: □ Means of subsistence
□ Ordinary passport □ Diploma c passport □ Service passport □ Official passport □ Special passport □ □ Invita on
Other travel document (please specify):
13. Number of travel document: 14. Date of issue: 15. Valid until: 16. Issued □ TMI
by □ Means of transport □ Other:
10297829 15/03/2017 14/03/2027 (country):
17. Personal data of the family member who is an EU, EEA or CH citizen if applicable Visa decision: □ Refused
□ Issued:
□A
□C
Surname (Family name): □ LTV
□ Valid:
Date of birth (day month year): Nationality:
From:
18. Family relationship with an EU, EEA or CH citizen if applicable:
□ spouse □ child □ grandchild □ dependent ascendant Until:
□ Registered Partnership □ other:
19. Applicant's home address and e mail address: Telephone no.: Number of entries:
□ 1 □ 2 □ Multiple
LUMBINI,32907 LUMBINI,Nepal - RISHI100JO@HOTMAIL.COM
20. Residence in a country other than the country of current nationality: Number of days:
□ No
□ Yes. Residence permit or equivalent ………………… No. …………………. Valid until……………………..
* 21. Current occupation:
EMPLOYEE
* 22. Employer and employer’s address and telephone number. For students, name and address of educational
establishment:
GANDAKI MEDICAL COLLEGE TEACHING HOSPITAL AND RESEARCH CENTER(GMCTHRC)
NAYABAZAR RD, POKHARA 33700
33700 POKHARA Nepal
061538595
23. Purpose(s) of the journey:
□ Tourism □ Business □ Visi ng family or friends □ Cultural □ Sports □ Official visit □ Medical reasons □ Study □
Airport transit □ Other (please specify):
24. Additional information on purpose of stay:
ESMO 2022 Congress

Annual
25. MemberCongress of the European
State of main destination Society
(and other Member States offor Medical Oncology
26. Member State of first entry:
09 - 13 September,
destination, if applicable): 2022- Paris, France
ITALY
27. Number of entries requested:
□ Single entry □ Two entries □ Mul ple entries
Intended date of arrival of the first intended stay in the Schengen area: Intended date of departure from the
Schengen area after the first intended stay:
28. Fingerprints collected previously for the purpose of applying for a Schengen visa: □ No □ Yes
Date, if known …………………….. Visa sticker number, if known

…………………………………………………………
29. Entry permit for the final country of destination, where applicable:
Issued by ………………………………..Valid from ……………………until ……………………
* 30. 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):
Address and e mail address of inviting person(s)/hotel(s)/temporary Telephone no.:

accommodation(s):
* 31. Name and address of inviting company/organisation:
Surname, first name, address, telephone no., and e Telephone no. of company/organisation:
mail address of contact person in
company/organisation:
* 32. Cost of travelling and living during the applicant’s stay is covered:
□ by the applicant himself/herself □ by a sponsor (host, company, organisation), please

specify:
Means of support: …….□ referred to in field 30 or 31
□ Cash …….□ other (please specify):
□ Traveller’s cheques
□ Credit card Means of support:
□ Pre paid accommoda on □ Cash
□ Pre paid transport □ Accommoda on provided
□ Other (please specify): □ All expenses covered during the stay □
Type text here Pre paid transport
□ Other (please specify):
I am aware that the visa fee is not refunded if the visa is refused.
Applicable in case a multiple entry visa is applied for:
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.
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 application; and any personal data concerning me which appear on the 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 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) 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 the Member State responsible (controller)
for processing the data is the Ministry of Foreign Affairs and International Cooperation (Piazzale della Farnesina 1, 00135 – Roma, website: www.esteri.it – e-
mail: dgit6@esteri.it).
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 Member State concerned. The Italian
national supervisory authority competent for the protection of personal data is the Guarantor for the Protection of Personal Data (Piazza di Montecitorio 121,
00186 Roma, www.garanteprivacy.it, tel. +3906 696771) which 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 6(1) of Regulation (EU) No 2016/399 (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.
Place and date: Signature:
(signature of parental authority/legal guardian, if applicable)

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Consulate General of Italy of Italy

Application for Schengen Visa

SHERCHAN Date of application:

3. First name(s) (Given name(s)): Application number:

8. Sex: 9. Civil status:

11. National identity number, where applicable: Supporting documents:

24. Additional information on purpose of stay:

ESMO 2022 Congress

Date, if known …………………….. Visa sticker number, if known

Issued by ………………………………..Valid from ……………………until ……………………

Address and e mail address of inviting person(s)/hotel(s)/temporary Telephone no.:

* 31. Name and address of inviting company/organisation:

□ by the applicant himself/herself □ by a sponsor (host, company, organisation), please

Place and date: Signature:

(signature of parental authority/legal guardian, if applicable)

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