Harmonised application form

Application for Schengen Visa

This application form is free

1 NLDMFA2411565500180630

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): FOR OFFICIAL USE ONLY
BARRY Date of application:
2. Surname at birth (Former family name(s)):
Application number:
3. First name(s) (Given name(s)):
Application lodged at:
AISSATA LAMARANA Embassy/consulate
Service provider
4. Date of birth 5. Place of birth: 7. Current nationality: Commercial intermediary
(day-month-year): Border (Name):
CONAKRY Guinean
21-10-2003
6. Country of birth: Nationality at birth, if ......................
......................
different:
Guinea Other:
Other nationalities: File handled by:
[-]
Supporting documents:
8. Sex: 9. Civil status: Travel document
Female Married Means of subsistence
Invitation
10. Parental authority (in case of minors) /legal guardian (surname, first name, address, if TMI
different from applicant’s, telephone no., email address, and nationality): Means of transport
Other:

Visa decision:
Refused
Issued:
11. National identity number, where applicable: A
C
12. Type of travel document: LTV
Ordinary passport Valid:
From: ......................
13. Number of 14. Date of issue: 15. Valid until: 16. Issued by
travel (country): Until: ......................
27-12-2023 27-12-2033
document:
DCPAF Number of entries:
O05173359 Guinea 1 2 Multiple
17. Personal data of the family member who is an EU, EEA or CH citizen or a UK
Number of days:
national who is a beneficiary of the EU-UK Withdrawal Agreement, if applicable:

Surname (Family name): First name(s) (Given name(s)):

1 No logo is required for Norway, Iceland, Liechtenstein and Switzerland. 1/6

 Date of birth Nationality: Number of travel
(day-month-year): document or ID card:
01-01-0001

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:

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

10 +221781811589
PIKINE TALLY BOUMACK
20600
15
Senegal
maubrommigime-7996@yopmail.com
20. Residence in a country other than the country of current nationality:
No, a residence permit is not required
* 21. Current occupation:
Unemployed
* 22. Employer and employer’s address and telephone number. For students, name and
address of educational establishment:

23. Purpose(s) of the journey:

Medical reasons
24. Additional information on the purpose of the stay:
CONSULTATION VERMIFUGE
25. Member State of main 26. Member State of first Duration of the
destination (and other entry: intended stay or transit
Member States of Indicate number of
Netherlands
destination, if days:
applicable):
11
1. Netherlands

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27. Number of entries requested:
Single entry
Intended date of arrival of the first intended stay in the Schengen area: 18-12-2024
Intended date of departure from the Schengen area after the first intended stay: 28-12-2024
28. Fingerprints collected previously for the purpose of applying for a Schengen visa: No

29. Entry permit for the final country of destination, where applicable:

* 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):
1. Netherlands:
ASTON CITY HOTEL

Address and e-mail address of inviting Telephone no.:

person(s)/hotel(s)/temporary accommodation(s):
1. Netherlands:
1. Netherlands: -
STADHOUDERSKADE 68
NETHERLANDS
1072 AD
AMSTERDAM
Netherlands

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

1. chiropractie wormerveer
Roode Wildemanweg 19
Wormerveer, Netherlands
1521 PZ
WORMERVEER
Surname, first name, address, telephone no., and e- Telephone no. of company/organisation:
mail address of contact person in
1. +31680227492
company/organisation:
1. Sophie FRINGANT
Roode Wildemanweg 19
Wormerveer, Netherlands
1521 PZ
WORMERVEER
Netherlands
info@chiropractie-wormerveer.nl
+31680227492
* 32. Cost of travelling and living during the applicant’s stay is covered:

By the applicant himself/herself By a sponsor (host, company, organisation),

please specify:

Means of support: Means of support:

- Cash

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Privacy Statement regarding Short Stay Visa Applications
Legal Basis and Meaning
Legislation is necessary to protect people’s privacy. In May 2018 the General Data Protection Regulation (GDPR)
came into force in all European Union member states. In the Netherlands this Regulation replaced the Personal Data
Protection Act (WBP).
The GDPR regulates the protection of personal data, i.e. information that can be traced back to an individual. The
aim is to ensure that people know who is processing their data, what data is being processed and for what purpose.
How does the Ministry of Foreign Affairs (BZ) handle your personal data?
Because the work done at BZ often entails working with personal data, it is important to ensure that people’s privacy
is protected and that privacy legislation is complied with at all times. The statement below explains how BZ ensures
this.
Information concerning your visa application
Why we need information about you
To assess your visa application, we need information from you. You provide this information on the visa application
form. Without this information no decision can be made on your visa application. You will only be asked for
information that is needed to make this decision.
The information you need to fill in relates to yourself and your sponsor, if you specify one. BZ uses this information
to make a decision on your visa application, which is one of its public tasks.
Sharing your personal data with third parties
The details you fill in on the visa application form and information regarding the decision on your application or, if
relevant, the decision to cancel, revoke or extend your visa are entered into the National Visa Information System
and the European Visa Information System (VIS).
It is important that your application is properly assessed. For this purpose the personal details on your visa
application form, as well as your fingerprints and photo, are shared with the competent authorities in the other EU
member states before a decision is made. Information entered in VIS can be accessed by visa authorities, by the
authorities competent to carry out visa checks at external borders and within member states, and by member states’
immigration and asylum authorities.
Information is shared so that authorities can check whether the conditions for lawful entry into and lawful residence
within the territory of the member states have been met, to determine which individuals do not or no longer meet
these conditions, and to investigate an asylum application and establish who is responsible for carrying out this
investigation. Under certain conditions, Europol and designated authorities in the member states also have access to
the information, in order to prevent, detect and investigate terrorist offences and other serious crime.
When you use our services, such as when applying for a Schengen visa, we may share some of your personal data
with third parties. This takes place in countries where the Dutch Ministry of Foreign Affairs cooperates with External
Service Providers for handling your visa application. The ministry works together with two companies in this ;
TLScontact (only in China) and VFSglobal (in the rest of the world). Both companies also work for other Schengen
Member States.
When we process your Schengen visa application (National Visa Information System), we engage external parties
(Processors) form the it-sector, for both the management of the systems being used, and also for hosting the
computer servers required for this purpose. These parties are located in the Netherlands in respectively Utrecht and
Amsterdam. When we share your personal data with Processors, we ensure that your personal data is protected in
accordance with the GDPR and this Privacy Statement through the Processor Agreements we have entered into with
our third parties.
To ensure that your visa application is assessed as quickly and effectively as possible, BZ uses a method based on
data analysis called Information-Supported Decision-Making. This method involves comparing the information
provided in your visa application with information held in a specially designed secure database called the BZ
Application Assessment Database (BAO). A special factsheet has been drawn up to explain which information is
used and how it is processed.
Your rights
You are entitled to ask what information about you is stored in the National Visa Information System and BAO. You
are also entitled to correct incorrect information and request that information be removed, subject to statutory

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provisions. You can apply to individual member states to find out what information about you is stored in the VIS
and to exercise your other rights. Finally, you are entitled to object to your personal data being entered into
databases.
Retention period for personal data
Your personal data will be stored in the National Visa Information System, BAO and VIS for up to five years.
Contact
If you have any questions or requests concerning your personal data, please write to: Ministry of Foreign Affairs,
Consular and Visa Affairs Department (HDCV), P.O. Box 20061, 2500 EB Den Haag. You may also submit a
question or complaint regarding the processing of your personal data to the national supervisory authority: Data
Protection Authority, P.O. Box 93374, 2509 AJ Den Haag.

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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.
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 is: Ministry of Foreign Affairs, Consular and Visa Affairs
Department (HDCV), Postbus 20061, 2500 EB DEN HAAG.
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
[Autoriteit Persoonsgegevens, Postbus 93374, 2509 AJ DEN HAAG] 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:

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

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