System Zdalnej Rejestracji
System Zdalnej Rejestracji
e-Konsulat
Home page > New Delhi > Visa > National Visa - Fill in form > Registration of visa application
This template will allow for the filling out and printing of your visa
application only. To make an appointment in a selected Consular
office, you are required to register your visa application.
Visa
National Visa -
form
Register
Application for national visa
National Visa - Fill in form
Fields No: 1, 2, 3, 5, 11, 13, 16, 31, 34 should be filled in by using the Latin alphabet letters only (A, B, C,
Schengen Visa - Register D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z). Any erroneous entry shall make the
form application void.
Schengen Visa - Fill in form
Personal data
1. Surname (s) (family name(s))
Visits
Legal matters 2. Surname (s) at birth (previously used surname (s))
Cancel appointment
3. First name(s)
5. Place of birth
6. Country of birth
7. Current nationality/ies
Passport data
12. Type of travel document
Ordinary passport
Diplomatic passport
Service passport
Official passport
Special passport
Other travel document (please specify):
16. Issued by
10.In the case of minors: Surname, first name, address (if different from applicants)
and nationality of parental authority/legal guardian
does not apply
Nationality
First name
Surname
Country
State/province
Place
Postal code
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System Zdalnej Rejestracji https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...
Address
State/province
Place
Postal code
Address
Current email
Email address. Other e-mail addresses than the one provided in the VISA Application
Form shall not be used when contacting an applicant.
Phone area code
Phone number
Number
Expiry date indefinitely
* 20. Employer and employers address and phone number. For students, name and address of school
Employer
School
State
State/province
Place
Postal code
Address
Phone
Name
Number of fax
Business
Cultural
Sports
Official visit
Medical reason
Study
Two entries
Multiple entries
29. Intended date of arrival to the Republic of 30. Intended date of departure from the Republic of
Poland (year-month-day) Poland (year-month-day)
The fields marked with * shall not be filled in by family members of EU, EEA or CH citizens (spouse, child or dependent
ascendant) while exercising their right to free movement. Family members of EU, EEA or CH citizens shall present
documents to prove this relationship and fill in fields No 34 and 35.
No
Yes. Date(s) of validity
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System Zdalnej Rejestracji https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...
27. Fingerprints collected previously for the purpose of applying for a Schengen visa
No
Yes
28. Entry permit for the final country of destination, where applicable
does not apply
Person
Type
Company
Name
First name
Surname
Country
Place
Postal code
Phone number
Number of fax
Address
House number
Flat number
E-mail address
EU citizen data
34. Personal data of the EU or EEA citizen you depend on. This question should be answered only by family
members of EU or EEA citizens.
Nationality
spouse
child
Relationship:
grandchild
dependent ascendant
Applicant's data
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 (cf. Field No 24): 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.
I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware
that the submission of an application and/or supplementary documents containing untrue personal data or false
information, declaration of untruth or the suppression of truth, forgery or tampering with a document with the intent
of passing it off as genuine or the use of such a document as genuine will lead to my application being rejected or to
the annulment of a national visa already granted, and may also render me liable to prosecution under Polish law. I
undertake to leave the territory of the Republic of Poland not later than the last day of the national visas validity. I
am aware that possession of a visa is only one of the prerequisites for entry into the territory of the Republic of
Poland. The 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 the Law on Aliens and am refused entry. The prerequisites for entry will be
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System Zdalnej Rejestracji https://secure.e-konsulat.gov.pl/Wiza/FormularzWiza.aspx?guid=c2827...
checked again on entry into the territory of the Republic of Poland. I am aware that a granted national visa may be
revoked if I no longer meet the requirement for its issuance.
* Questions marked with * may be omitted by family members of EU or EEA citizens (spouse, child, or dependent
ascendant). Family members of EU or EEA citizens have to present documents proving this relationship.
Please make sure that the data entered in the Visa Application Form are correct and press SAVE button to confirm it.
Press CORRECT button if you need to amend any data you have entered in the Application Form. Any erroneous
entry shall make the application void.
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