APPLICATION FOR SCHENGEN VISA PHOTO

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): ROMANE FOR OFFICIAL USE ONLY

2. Surname at birth (Former family name(s)): Romane Rofia

Date of application:
3. First name(s) (Given name(s)): ROFIA
Application number:
4. Date of birth 5. Place of birth: 7. Current nationality:
(day-month-yar):
EL EULMA ALGERIA
31/01/2000
6. Country of birth: Nationality at birth, if different:
Application lodged at:
ALGERIA ALGERIA
□ Embassy/consulate
Other nationalities:
□ Service provider
□ Commercial intermediary
8. Sex: 9. Civil status: □ Border (Name):
□ Male ■ Single □ Married □ Registered Partnership …………………………
■ Female □ Separated □ Divorced □ Widow(er) …………………………
□ Other (please specify): □ Other:
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different from applicant's,
telephone no., e-mail address, and nationality):
File handled by:

11. National identity number, where applicable: 306385556

Supporting documents:
12. Type of travel document: □ Travel document
■ Ordinary passport □ Diplomatic passport □ Service passport □ Official passport □ Special passport □ Means of subsistence
□ Other travel document (please specify):
□ Invitation
13. Number of travel document: 14. Date of issue: 15. Valid until: 16. Issued by (country): □ TMI
306385556 16/05/2025 17/05/2030 ALGERIA □ Means of transport
EL EULMA □ Other:

17. Personal data of the family member who is an EU, EEA or CH citizen if applicable

Surname (Family name): First name(s) (Given name(s)): Visa decision:

□ Refused
□ Issued:
□A
Date of birth (day-month-year): Nationality: Number of travel document or ID card:
□C
□ LTV

18. Family relationship with an EU, EEA or CH citizen if applicable:

□ Valid:
□ Spouse □ Child □ Grandchild □ Dependent ascendant
From:
□ Registered Partnership □ Other:
Until:
19. Applicant's home address and e-mail address: Telephone no.:
Number of entries:
1 NOVEMBER 1954 Promotion Ragueb Saou Meziane +213553147139
□ 1 □ 2 □ Multiple
19600 EL EULMA
ALGERIA Number of days:
ggig47388@gmail.com
20. Residence in a country other than the country of current nationality:
■ No
□ Yes. Residence permit or equivalent No Valid Until

*21. Current occupation: Student

* 22. Employer and employer's address and telephone number. For students, name and address of educational
establishment:
Educational establishement: Université setif 2
El Hidheb , 19600, setif, ALGERIA

23. Purpose(s) of the journey:

■ 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: Partir en visite et rentrer à la maison pour étudier

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

27. Number of entries requested:

□ Single entry ■ Two entries □ Multiple entries
Intended date of arrival of the first intended stay in the Schengen area: 11/09/2025
Intended date of departure from the Schengen area after the first intended stay: 18/09/2025

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):
Hotel or temporary accomodation: B&B HOTEL Namur

Address and e-mail address of inviting Telephone no.:

person(s)/hotel(s)/temporary accommodation(s):
40 Boulevard Ernest Mélot +3281234010
5000 Namur Belguim
BELGIUM
bb_7505@hotelbb.com

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

Surname, first name, address, telephone no., and e-mail Telephone no. of company/organisation:
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:
□ referred to in field 30 or 31
□ other (please specify):

Means of support:
Means of support:
□ Cash
□ Cash
□ Accommodation provided
□ Traveller's cheques
□ All expenses covered during the stay
□ Credit card
□ Pre-paid transport
□ Pre-paid accommodation
□ Other (please specify):
□ 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 for processing the data is:
Federal Public Service Home Affairs, Immigration Office, Direction of Access and Residence, Bd Pachéco 44, 1000 Brussels, Belgium
dpo.dvzoe@ibz.fgov.be, +32 2 793 80 00, www.dofi.ibz.be
FPS Foreign Affairs, Foreign Trade and Development Cooperation, Rue des Petits Carmes / Karmelietenstraat 15, 1000 Brussels, Belgium
DPO@diplobel.fed.be, +32 2 501 81 11, www.diplomatie.belgium.be

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, the DPA (Data Protection Authority)
Data Protection Authority, Rue de la Presse 35, 1000 Brussels, Belgium
contact@apd-gba.be , +32 2 274 48 00, www.dataprotectionauthority.be
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):