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VISA APPLICATION FORM
Stamp of office
Issuing visa
1. Surname
FOR CONSULATE USE
ONLY
Data złożenia wniosku:
2. Maiden name / Previous surnames
Przyjmujący wniosek:
3. Given names
4. Date of birth (YY – MM - DD)
5. Identification number (if applicable)
Dodatkowe dokumenty:
6. Place and country of birth
Ważny dokument
podróży
7. Present citizenship(s)
8. Citizenship at birth
Zaproszenie
Środek transportu
9. Sex
10. Marital status
Ubezpieczenie
male
female
single
married
separated
Inne:
divorced
widowed
other
11. Father’s given name
12. Mother’s given name
Wiza:
13. Type of travel document
Odmowa
Passport
Diplomatic passport
Service passport
Travel document for aliens
Udzielona
Travel document (as in Geneva Convention of 1951)
Seaman’s book
Other travel document (what type):
..........................................................................................................................................
Typ wizy / cel pobytu:
14. Travel document number
15. Issued by
A
B
16. Date of issue
17. Valid until
C /..........
D /..........
W /..……
18. If you reside in another country than country of your origin – do you have permission to return to this
country?
No
Yes (document number and date of validity)
.....................................................................................
19. Present job
20. Employer’s address and telephone number. For students – name and address of school / university
21. Country of destination (in case of
22. Visa class
23. Visa applies to:
Ilość wjazdów:
transit)
Airport
One person
1
2
wiele
Transit
More * ........(how many)
Ważna od ........................
do ....................................
Short stay
Long stay
Entry
24. Number of entries requested
25. Period of stay:
Ważna na .................. dni
single entry
double entries
multiple entries
visa is requested for _________ days
26. Polish visa(s) (issued in last 3 years) and their period(s) of validity:
27. If you are applying for a transit visa, do you have permission to enter a country of destination?
Pieczęć i podpis organu
wydającego wizę
No
Yes, valid until do:
issued by:
* 28. Countries visited in the last 5 years
* Only applicable when multiple family members are included in one travel document.