Harmonised application form

Application for Schengen Visa

This application form is free PHOTO

Family members of EU, EEA or CH citizens or of UK nationals who are beneficiaries of the EU-UK Withdrawal Agreement
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] : UCHE For official use only

Date of application :
2. Surname at birth [former family name(s)] : 26/08/2024
Application number :
FRA1LA20247 059129
3. First name(s) [given name(s)] : Esther Nneka
Application lodge at :
 Embassy/consulate
4. Date of birth (day-month- 5. Place of birth : 7. Current nationality :  Service provider
year) : 03/04/1993 Nigerian
LAGOS  Commercial
intermediary
Nationality at birth, if different :
 Border
6. Country of birth :
(name) :
Nigeria Other nationalies :
 Other :

File handled by :

Supporting documents :
8. Sex : 9. Civil status :  Travel document
 Single 
■ Married  Registred partnership  Separated
 Means of subsistence
 Male 
■ Female  Other  Divorced  Widow(er)  Other (specify) :
 Invitation
10. Parental authority (in case of minors)/legal guardian (surname, first name, address, if different from applicant’s,  TMI
telephone No, email address, and nationality) :  Means of transport
 Other :

Visa decision :
 Refused
 Issued
 A
11. National identity number, where applicable : 86233984235  C
 LVT

12. Type of travel document :

■ Ordinary passport  Diplomatic passport  Service passport  Official passport  Special passport
 Other travel document (please specify) : Valid :

13. Number of travel document : 14. Date of issue : 15. Valid until : 16. Issued by (country) : From .......….…….…..
25/02/2021 24/02/2026 ………
B00329719 Nigeria
Until.....…….….……
….…....
17. Personal data of the family member who is an EU, EEA or CH citizen or a UK national who is a beneficiary of the EU-
UK Withdrawal Agreement, if applicable : Number of entries :
 1  2  Multiple
Surname (family name) : First name(s) [given name(s)] : Number of days : ............

Date of birth (day-month-year) : Nationality : Number of travel document or ID card :

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*FRA1LA20247059129*
18. Family relationship with an EU, EEA or CH citizen or a UK national who is a beneficiary of the EU-UK Withdrawal Agreement, if applicable :

 Spouse  Child  Grandchild  Dependent ascendant  Registered partnership  Other

19. Applicant’s home address and email address : Telephone no :

IJEGUN IMORE, NEW SITE ,JOSEPHAT +2347069366762
100001
LAGOS
Nigeria
[email protected]

20. Residence in a country other than the country of current nationality :


■ No  Yes : Residence permit or equivalent N°…………….…..…..….……………….…… Valid until………..…………..

* 21. Current occupation :

Other : Project Coordinator

* 22. Employer and employer’s address and telephone number. For students, name and address of educational establishment :
GOLDEN EMIRATES AGRO GLOBAL RESOURCES
IKOSI ROAD,INLAND TOWN,ANAMBRA, ONITSHA
Nigeria, +2348183675247, [email protected]

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 :

I'm primarily visiting for tourism, but I'm also attending a four-day Python conference in Strasbourg from October 31st to November 3rd.
My company sponsored this conference to support my professional development.

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

27. Number of entries requested :


■ Single entry  Two entries  Multiple entries
Intended date of arrival of the first intended stay in the Schengen area : 28/10/2024
Intended date of departure from the Schengen area after the first intended stay : 08/11/2024

28. Fingerprints collected previously for the purpose of applying for a Schengen visa :
■ No  Yes Date, if know : ……….…………. Number of the visa, if know :………………………………………………

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 TANDEM - BOUTIQUE HOTEL

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Address and email address of inviting person(s)/hotel(s)/temporary accommodation(s) : Telephone no :

2 PLACE DE LA GARE, STRASBOURG SUBURBS, STRASBOURG, 67000, STRASBOURG 0185148161

France
[email protected]

* 31. Name and address of inviting company/organisation : Telephone no of company/

organisation :

Surname, first name, address, telephone no, and email address of contact person in company/organisation :

* 32. Cost of travelling and living during the applicant’s stay is covered :


■ by the applicant 
■ by a sponsor (host, company, organisation), please specify :
 referred to in field 30 or 31
Means of support :
■ Other (specify) : GOLDEN EMIRATES AGROGLOBAL

■ Cash
RESOURCES
 Traveller’s cheques

■ Credit card

■ Pre-paid accommodation Means of support :

■ Pre-paid transport 
■ Cash
 Other (specify) :  Accomodation provided
 All expenses covered during the stay

■ Pre-paid transport

■ Other (specify) : COST INCURED DURING THE
CONFERENCE

33. Surname and first name of the person filling in the application form, if different from the applicant :

Address and email address of the person filling in the application form : Telephone no :

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*FRA1LA20247059129*
I am aware that the visa fee is not refunded if the visa is refused.

Applicable in case a multiple-entry visa is issued

I am aware of the need to have 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 are : Ministère de
l’Intérieur (Place Beauvau -75800 Paris CEDEX 08) et le Ministère de l’Europe et des Affaires Etrangères (27 rue de la Convention –75732 PARIS Cedex 15).
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 [ Commission Nationale de l'Informatique et des Libertés – 3 Place de Fontenoy - TSA 80715 - 75334 PARIS CEDEX 07 ] 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) 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 of applicant (signature of parental authority/legal guardian, if applicable) :
26/08/2024 19: 40: 38 (hour of
Lagos)

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