APPLICATION FOR VISA

This application form is free PHOTO

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): La Rotta Forero FOR OFFICIAL

USE ONLY
Date of
2. Surname at birth (Former family name(s)): La Rotta Forero application:

3. First name(s) (Given name(s)): Luis Alejandro

Application
number:

4Date of birth 5
Place of birth: 7. Current Application
.(day-month- . nationality: lodged at:
year):
Colombian ☐Embassy/
28-05-1978 consulate
Nationality at
6. Country of birth:
birth, if different: ☐Service
Colombia provider
☐Commercial
Other
intermediary
nationalities:

8. Sex: 9.Civil status: ☐Border

(Name):
☐ Male ☐ Single ☐ Married ☐ Registered Partnership ☐
Separated ☐ Divorced ☐ Widow(er) ☐ Other …
☐ Female
(please specify):
…
☐ Other:

10 Parental authority (in case of minors) /legal guardian File handled by:
. (surname, first name, address, if different from applicant's,
telephone no., e-mail address, and nationality):

11. National identity number, where applicable: Supporting

documents:
12 Type of travel document: ☐Travel
. document
☐ Ordinary passport ☐ Diplomatic passport ☐ Service
passport ☐ Official passport ☐ Special passport ☐Means of
 subsistence

1Number of 14 Date of 15 Valid 16. Issued by ☐ TMI

3travel . issue: . until: (country):
☐Means of
. document: 17/01/2017 17/01/202 Colombia transport
AT556589 7
☐ Other:
Visa decision:

☐ Refused
17 Personal data of the family member who is an EU, EEA or CH
. citizen if applicable ☐ Issued:
☐ A
Surname (Family name): First name(s) (Given name(s)):
☐ C

☐ D
Date of birth Nationality: Number of travel
(day-month- document or ID card:
year): ☐ LTV
☐ Valid:
18.Family relationship with an EU, EEA or CH citizen if applicable:
From:
☐ spouse ☐ child ☐ grandchild ☐ dependent ascendant Until:
☐ Registered Partnership ☐ other:

19 Applicant's home address and e-mail Telephone no.:

. address:

20 Residence in a country other than the country of current

. nationality:
☐ No
☐ Yes. Residence permit or equivalent … No … Valid until …

*21. Current occupation: PNC Bank Core support Number of

entries:
*22. Employer and employer's address and telephone number. ☐1☐2☐
For students, name and address of educational Multiple
establishment: Number of days:
New Bulgarian University, 1618 Sofia, Bulgaria 21 Montevideo Str.,

+359 2 811 0110

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23 Purpose(s) of the journey: Masters Degree
.
☐ 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:

25 Member State of main 26. Member State of first entry:

. destination (and other
Member States of
destination, if applicable):

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 Telephone no.:

of inviting
person(s)/hotel(s)/temporar
y accommodation(s):

3
*31. Name and address of inviting company/organisation:

Surname, first name, Telephone no. of

address, telephone no., and company/organisation:
e-mail 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,

himself/herself organisation), please specify:
Means of support: … ☐ referred to in field 30 or 31
… ☐ other (please specify):
☐ Cash
Means of support:
☐ Traveller's cheques
☐ Cash
☐ Credit card
☐ Accommodation provided
☐ Pre-paid accommodation
☐ All expenses covered during the
☐ Pre-paid transport
stay
☐ 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. (yes)

I am aware of 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,

4
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: [(…)].
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 [contact details: …] 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:

5
(signature of parental authority/legal
guardian, if applicable):