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Consulate General of Italy
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Boston
Photo
A pplication for National V isa (D)
T his application form is free
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1. Surname (s) (family name(s) ) (x)
Y O U R L AST N A M E E X A C T L Y AS I T A PP E A RS O N Y O U R P ASSPO R T
...........................................
F O R E M B ASSY
/C O NSU L A T E USE O N L Y
2. Surname(s) at birth (former family name(s)) (x)
M A I D E N N A M E I F A PP L I C A B L E O T H E R W ISE L E A V E B L A N K
3. F irst names (given names) (x)
F I RST A N D M I D D L E N A M E E X A C T L Y AS I T A PPE A RS O N Y O U R P ASSP O R T
4. Date of birth (day-month-year)
......................................
E X A M PL E : M A R C H 24, 1991
SH O U L D APPE A R 24 ± 03 - 1991
5. Place of birth/.................
C I T Y A N D ST A T E O F
BIR T H
Date of application:
7. C u r r ent nationality
«««««««««
V isa application number :
U.S. A N D/ O R O T H E R N A T I O N A L I T Y
Nationality at bi rth, if different:
A pplication lodged at:
............................................................
U .S. A N D/ O R O T H E R N A T I O N A L I T Y
E mbassy/Consulate
C ity hall C A C
9. M arital status«««««««
Service provider
C H E C K A PP R O P R I A T E B O X
Commercial Intermediary
Single
M a r r ied
O ther
Sep a r ated
D ivor ced
W idow/er
Name:
O the r (please specify)««««««««««««««««««
6. C ount r y of bi r th/........................
C OUNTRY O F BIRT H ± DO NO T
ABBRE VIA T E
8. Sex«««««««
M ale
F em ale
C H E C K A PP R O P R I A T E B O X
10. In the case of minors: Surname, fi rst name, addr ess (if different from applicant¶V) and nationality of pa rent al authority/
legal gua rdian/......................................... ...............................
F ile handled by:
I F A PPL I C A B L E , C O M P L E T E AS I NST R U C T E D
11. N ational I dentity number , whe re applicable/...................................................................... L E A V E T H IS B L A N K
Name of person who received
file at window:
12. T ype of t r avel documen t/................................................
O r din a r y p asspor t
Se r vice p asspor t
Special passport.
O ther t r avel document (please specify)
D iplom atic p asspor t
O fficial p asspor t
You can find this
in your passport
stated under
³A uthority´
C H E C K ³O R D I N A R Y P ASSP O R T ´
Supporting documents:
T ravel document
Means of substance
I nvitation
Means of transport
T ravel H ealth insurance
O ther
16. Issued by«««««
14. D ate of issue««««« 15. V alid until«««««
L IST T H E PL A C E (COUNTRY)
D A Y-M O N T H-Y E A R
D A Y-M O N T H-Y E A R
W H E RE Y O UR
Y O U R P ASSP O R T W AS
Y O U R P ASSP O R T IS
P ASSP O R T W AS ISSU E D
ISSU E D
V A L ID UNT I L
T elephone number (s)««««««
17. $SSOLFDQW¶VKRPHDGGUHVVDQGH-m ail ad d r ess
V isa decision:
...............................................................
Refused
B EST C O N T A C T N U M B E R I N C L.
Y O U R C O M P L E T E H O M E A D D R ESS A N D E M A I L A D D R ESS
Refused for SIS non
AREA CODE
cancellable.
18. R esidence in a count r y othe r than the count r y of cu r r ent nationality /.....................................
Suspended F ile
N o C H E C K µ N O ¶ U N L E SS Y O U A R E L I V I N G I N A C O U N T R Y O T H E R T H A N Y O U R H O M E C O U N T R Y
Issued
Y es. R esidence pe r m it or eq u ivalen t / ................................ N o««««««« V alid until«««««««
T ype of visa:
D
19. C ur rent occupation«««««««««««««
W R I T E ³ST U D E N T´
V alid:
20. (PSOR\HUDQGHPSOR\HU¶VDGGUHVVDQGWHOHSKRQHQXPEHU . F or students, n ame and ad d r ess of ed ucation al
13. N umbe r of t r avel
document««««««
P ASSP O R T N U M B E R
establish m en t. L I S T T H E U .S. S C H O O L Y O U A R E A T T E N D I N G W I T H C O M P L E T E A D D R E SS
................................................ ................................................ ........................... .....................
21. M ain Purpose(s) of the journey/.........................................................
C H E C K ³ST U D Y´
F amily reunion/V isiting F amily
Religious
M edical treatment
Self employment
Sports
Study
O ther (please specify)
B usiness
A doption
(x) In fields from 1 to 3 information must be inserted as it appears on travel documents.
from ««««««««««
until««««««««««
Number of entries:
D iplomatic
E mployment
1
2
M ultiplie
Numero di giorni:
««««««««««««
1
22. C ity of destination
W R I T E ³I T A L Y, B O L O G N A´
23. State of fi rst entr y
W R I T E C I T Y A N D C O U N T R Y W H E R E Y O U R F I RST
F L I G H T L A N DS A F T E R D E P A R T I N G T H E U.S.
24. Number of entries requested/ ...............................:
25. Dur ation of the stay. Indicate number
of days (max. 365 days) /
.......................................................:
L IST T H E N U M B E R O F D A YS O F T H E T E R M
O n e / . .. . . .
T w o/ . .. . . .
M ultiple/.............
C H E C K ³M U L T IP L E´
26. Schengen visas issued during the past three years / ......................... ........................:
N o/... L I S T O T H E R V I S A S O B T A I N E D , O T H E R W I S E , C H E C K ³ N O ´
Count O N L Y the number of
days of the program from
³Housing C heck In´ to
³Housing C heck O ut.´
EVEN IF YOU ARE
A R R I V I N G A F E W D A YS
BE F ORE OR L E A VING A
F E W D A YS A F T E R T H E
PR O G R A M. For full year
students, count from
³Housing C heck In´ of the
first term until the last day
of ³F inal E xams´ of the
second term.
Yes. Date(s) of validity / .............. from/....«««««««««««to /.. «««««««««««««
Must
match
flight
itinerary
27. F inger pr ints ta ken previously for the pur pose of applying for a Schengen visa
................................................ .................... . . .............................................:
C H E C K ³N O´ U N L E SS T H IS A PP L I E S T O Y O U
N o/...
Y es/.... Date, if known/......................
«««««««««««««««««««««««««««««««
28. Number of no objection document issued for family reunification/accompanying family/employment (only in
case where required by legislation gover ning the type of being requested)/ ...........................................................
Issued by SU I of /.......................................... «««««««««««« D O E S N O T A PP L Y W R I T E µN A¶
V alid f rom/.....................««««««««««««««««««until/....««««««««««««««««««
29. Intended date of a r r ival in the Schengen a rea
30. Intended date of depar ture from the Schengen area
......................................................................
(only for visas valid for stays of between 91-364 days)
DD/MM/YYYY
DD/MM/YYYY
..........................................................
A C T UA L DA T E Y O U WI L L ARRI V E
A C T U A L D A T E Y O U W I L L D E PA R T
31. Sur name and first name of the inviting person or employer. If not applicable, in case of visa for A doption,
Religious reasons, M edical reasons, Spor ts, Study, M ission: address of institution in Italy.
...................................................................... .................................... .......... ......................................... .
L IST I NSI T U T I O N I N I T A L Y
B rown in Italy, V ia Belmeloro 7, 40126 Bologna, Italy
Phone: 39-051-2960906
A ddress and e-mail address of inviting person(s) or
employer
................................................................................
T elephone and fax of inviting person(s) or
employer...............................................
32. Name and address of inviting company/organisation
/.......................................................
T elephone and fax of company/organisation
.................................................................
T he Schengen area
includes: A ustria,
Belgium, Denmar k,
F inland, F rance,
Germany, G reece,
Iceland, Italy,
L uxemburg, T he
Netherlands, Norway,
Portugal, Spain and
Sweden.
Sur name and first name, address, telephone, fax and e-mail address of contact person in company/organisation/
.......................................................................................................................................................
33. Cost of travelling and living expenses is covered by /.......................................................................:
by the applicant himself/herself/
.......................................... C H E C K ³ H I MSE L F/ H E RSE L F´
Means of support/..........................................:
C H E C K A L L T H A T APPL Y
C ash/ ..............................
T raveller's cheques/................................
C redit ca r d/..................................
Prepaid accommodation/..........................
Pr epaid tr anspor t/...............................
O ther (please specify)/...............:..................................
STATEMENT NOT NECESSARY FOR FOLLOWING
VISAS:
Family reunion, Accompanying Family, Employment/Selfemployed, Business, Diplomatic, Adoption.
by sponsor (host, company, organisation),
specify/ ........................................................
«««««««««««««««««
Refe r r ed to in field 31 or 32 / .......................
othe r (please
specify)/..........................«««««««
Means of support/..............................:
C ash/....................
Accommodation provided..................................
A ll expenses covered during the stay/
....................................................
Prepaid transport/.....................
O ther (please specify)/ ..........(..........««««««
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W R I T E ³N/ A´. I F Y O U A R E A N E U C I T I Z E N C O N T A C T T H E O IP
34. Personal data of the family member who is an E U, SE E or C H citizen / .........................................................................
Surname / ................
Date of birth / ....................
F irst name(s) / ......................
Nationality / .......................
Number of travel document or I D card
..............................................
35. Family relationship with an E U, SE E or C H citizen/ ........................................................................:
spouse/................
child/ ........./..
other direct descendant/............
dependent ascendant/.............................
36. Place and date / ................................
37. Signature (for minors, signature of parental
authority/legal guardian)/ .......... (............................................)
W R I T E ³B OST O N´ A N D T H E D A T E D D-M M-Y Y Y Y
SI G N Y O U R N A M E I N B L U E I N K
.............................................................................................................................................................................
...........................................................................................................................................
I am aware that the visa fee is not refunded if the visa is refused.
N/A LEAVE BLANK
........................................................................... ...........................................................................................
I am aware of and consent to the collection of the data required by this application form and the ta king of my photograph and , if applicable, the
ta king of fingerprints. I understand these, are mandatory for the examination of the visa application. A ny personal data concerning me which
appear on the visa application form, as well as my fingerprints and my photograph, will be supplied to the relevant Italian authorities and
processed by those authorities , for the purposes of a decision on my visa 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, and stored in the Information System of this Consulate G eneral, and the Ministry of Foreign Affairs. Such data will be accessible to the
competent Italian visa authorities. It will be accessible to the competent Schengen authorities in order to check 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 in the territor y 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 also
be accessible to authorities designated by the Member States and to E uropol for the purpose of the prevention, detection and i nvestigation of
ter rorist offenses and of other serious criminal offenses..
I am aware that I have the right to obtain the data transmitted relating to me recorded in the information systems and to request that data
relating to me which are inaccurate be cor rected and that data relating to me processed unlawfully be deleted. A t 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 cor rected or deleted, including the related remedies according to the national law.
T he national controlling A uthority is the G uarantor of protection of personal data.
I declare that to the best of my knowledge all information supplied by me are complete and correct. 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
Representative country under State legislation (articolo 331 c.p.p.).
T he 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 A rticle 5, paragraph 1 of Regulation (E U) No. 562/2006 (Schengen Borders Code) and of A rticle 4 of D. Lgs. 286/98 and I am
therefore refused entry.
A N N O T A T I O NS (
.
Office use only)
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Place and date / .......................
WRITE "BOSTON" AND THE DATE DD/MM/YYYY
Signatures (for minors, signature of pa rental authority/legal guar dian)
/ ..........................................................................................
SIGN YOUR NAME IN BLUE INK
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