Harmonised application form

Application for Schengen Visa

1
This application form is free

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) FOR OFFICIAL USE ONLY
EERA
2. Surname at birth (Former family name(s)) Date of application:

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

NADIA JEHAN
4. Date of birth (day-month-year) 5. Place of birth 7.Current nationality Application lodged at:
17-01-2017 DHAKA BANGLADESH
6. Country of birth Nationality at birth, if different
BANGLADESH Embassy/consulate
Other nationalities
Service provider
8.Sex 9. Civil status Commercial intermediary
Male Female Single Married Registered Partnership Border (Name)
………………………………..
Separated Divorced Widow(er)
………………………………..
Other (please specify): ………………………………………………..
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if different from applicant’s, Other:
telephone no., e-mail address, and nationality)

Jahid, MKA Shahinoor Rahman, H# 8, Road-12, Block-C, Sec-6, Mirpur, Dhaka

11. National identity number, where applicable

NOT APPLICABLE
12. Type of travel document File handled by:
Ordinary passport Diplomatic passport Service passport Official passport
Special passport Other travel document (please specify): …………………………………….
13. Number of travel document 14. Date of issue 15. Valid until 16. Issued by (country) Supporting documents:
A05280264 24-10-2022 23-10-2027 BANGLADESH Travel document
17. Personal data of the family member who is an EU, EEA or CH citizen or an UK national who is a Withdrawal Means of subsistence
Agreement beneficiary, if applicable Invitation
Surname (Family name) First name(s) (Given name(s)) TMI
Means of transport
Date of birth (day month year) Nationality Number of travel document or ID card Other:

18. Family relationship with an EU, EEA or CH citizen or an UK national who is a Withdrawal Agreement beneficiary,
Visa decision:
if applicable
Refused
Spouse Child Grandchild Dependent ascendant Issued:
Registered Partnership Other (please specify): ………………………………….. A
19. Applicant’s home address and e-mail address Telephone no. C
LTV
Mirpur, Dhaka-1216. shahinoor65@yahoo.com 8801683325571
20. Residence in a country other than the country of current nationality
Valid
No
From
Yes. Resident permit or equivalent …………..……………….. No ……..…………………….…..……..
Until
Valid until…………………………………………….……..
*21. Current occupation Number of entries
1 2 Multiple
STUDENT
*22. Employer and employer’s address and telephone number. For students, name and address of educational Number of days:
establishment.
MIGR_119031 2021-09-15

Mirpur Cantonment Public School & College. Mirpur, Dhaka-1216.

23. Purpose(s) of the journey
Tourism Business Visiting family or friends Cultural Sports
Official visit Medical reasons Study Airport transit
Other (please specify):………………………………………………………………………………………..

1
No logo is required for Norway, Iceland, Liechtenstein and Switzerland.
24. Additional information on purpose of stay FOR OFFICIAL USE ONLY

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

Amsterdam, Brussels, Paris Amsterdam

27. Number of entries requested
Single entry Two entries Multiple 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 Telephone no. of company/organisation

*Surname, first name, address, telephone no. and e-mail address of contact person in company/organisation

*32. Cost of traveling 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
Means of support ………………………………...…… other (please specify)
Cash Means of support
Traveler’s cheques Cash
Credit card Accommodation provided
Prepaid accommodation All expenses covered during the stay
Prepaid transport Prepaid transport
Other (please specify): 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 State.

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: The Swedish Migration Agency, 601 70 Norrköping, Sweden,
www.migrationsverket.se.
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
(Swedish Authority for Privacy Protection, Box 8114, 104 20 Stockholm, Sweden, www.imy.se) 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)

Dhaka.