Application for Schengen Visa

This application form is free

PHOTO
2170803010009898855
no attachment supplied

Family members of EU, EEA or CH citizens or of UK nationals who are Withdrawal Agreement beneficiaries
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): WYŁĄCZNIE DO

EVELINA UŻYTKU URZĘDOWEGO
Data złożenia wniosku:
2. Surname at birth (Former family name(s)):
- Numer wniosku:
3. First name(s) (Given name(s)):
Wniosek złożono:
NANGA □ w ambasadzie/konsulacie
4. Date of birth 5. Place of birth: 7. Current nationality: □ u usługodawcy
□ u pośredniczącego
MAQUELA DO ZOMBO ANGOLA
(day-month-year):
podmiotu komercyjnego
Nationality at birth, if different: □ na granicy (nazwa):
30-10-1982 6. Country of birth:
ANGOLA ………………………….
ANGOLA Other nationalities:
………………………….
□ inne:
ANGOLA

8. Sex: 9. Civil status:

X□ Single □ Married □ Registered Partnership □ Separated Wniosek przyjęty przez:
□ Male X□ Female □ Divorced □ Widow(er)
□ Other (please specify):
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different from Dokumenty uzupełniające:
applicant’s, telephone no., e-mail address, and nationality): □ dokument podróży
□ środki utrzymania
□ zaproszenie
□ podróżne ubezpieczenie
11. National identity number, where applicable: 003207765UE039 medyczne
12. Type of travel document: □ środek transportu
□ inne:
X
□ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport
□ Special passport □ Other travel document (please specify):
13. Number of travel 14. Date of issue: 15. Valid until: 16. Issued by (country):
document:
2018-10-15 2028-10-15 SME DE LUANDA Decyzja o wizie:
N2389100 □ odmowa
□ przyznano wizę:
17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who is a Withdrawal □A
Agreement beneficiary, if applicable: □C
Surname (Family name): First name(s) (Given name(s)): □ o ograniczonej ważności
terytorialnej
□ okres ważności:
Date of birth Nationality: Number of travel document or ID card:
(day-month-year): Od:

Do:
18. Family relationship with an EU, EEA or CH citizen or a UK national who is a Withdrawal Agreement
beneficiary, if applicable:
Liczba wjazdów:
□ spouse □ child □ grandchild □ dependent ascendant □ Registered Partnership □ 1 □ 2 □ wielokrotny
□ other: Liczba dni:
19. Applicant's home address and e-mail address: Telephone no.:
ANGOLA, LUANDA
0000 CACUACO, CASA SN, BAIRRO BELO MONTE 0 nangaevelina0023@gmail.com 00244 945931272
20. Residence in a country other than the country of current nationality:
X
□ No
□ Yes. Residence permit or equivalent ………………… No. ………….…………….
Valid until ……………………….……
*21. Current occupation:
TECNICA DE CONTABILIDADE

NANGA EVELINA, 2170803010009898855, no attachment supplied WIZA, 2023-03-01, Luanda

 *22. Employer and employer’s address and telephone number. For students, name and address of educational
establishment:KAMARFING, LDA
ANGOLA, LUANDA, 0000 CACUACO, BAIRRO DAS SALINHAS 123
00244911874072 kamarfing@gmail.com
23. Purpose(s) of the journey:
X
□ Tourism □ Business □ Visiting family or friends □ Cultural □ Sports

□ Official visit □ Medical reasons □ Study □ Airport transit

□ Other (please specify):
24. Additional information on purpose of stay:

25. Member State of main destination (and other 26. Member State of first entry:
Member States of destination, if applicable):
POLAND
PORTUGAL

27 Number of entries requested:

X
□ Single entry □ Two entries □ Multiple entries

Intended date of arrival of the first intended stay in the Schengen area: 2023-03-25

Intended date of departure from the Schengen area after the first intended stay: 2023-04-02
28. Fingerprints collected previously for the purpose of applying for a Schengen visa:
X
□ 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 Telephone no.:

person(s)/hotel(s)/temporary accommodation(s):

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

ARAMIS HOSTEL
POLAND, 02-758 VARSOVIA, Ul. Mangalia - Mazowieckie 3b
aramis@starthotel.pl
Surname, first name, address, telephone no., and e-mail Telephone no. of company/organisation:
address of contact person in company/organisation:
0048 0048222078000

*32. Cost of travelling and living during the applicant’s stay is covered:
X
□ by the applicant himself/herself □ by a sponsor (host, company, organisation), please
Means of support: specify:
X
□ Cash □ referred to in field 30 or 31
□ Traveller’s cheques □ other (please specify):
X
□ Credit card Means of support:
□ Pre-paid accommodation □ Cash
□ Pre-paid transport □ Accommodation provided
□ Other (please specify): □ All expenses covered during the stay
□ Pre-paid transport
□ Other (please specify):

NANGA EVELINA, 2170803010009898855, no attachment supplied WIZA, 2023-03-01, Luanda

 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 for processing the data is: Centralny Organ Techniczny KSI, Komendant Główny Policji,
Puławska 148/150, 02-624 Warszawa.

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 national supervisory authority of that Member State [contact details: Prezes Urzędu Ochrony
Danych Osobowych, ul. Stawki 2, 00-193 Warszawa] 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):

NANGA EVELINA, 2170803010009898855, no attachment supplied WIZA, 2023-03-01, Luanda

 2170803010009898855
no attachment supplied

Date of 2023-03-01 time: 09:00

appointment
Service passport Wiza Schengen
Location Luanda
Mission
Luanda
Rua Damião de Góis 64
C.P. 1340, Alvalade, Luanda
Phone 00 244 222 327 199, Fax 00 244 222 321 829

consul.luanda@msz.gov.pl

NANGA EVELINA, 2170803010009898855, no attachment supplied WIZA, 2023-03-01, Luanda