1. SURNAME(S)  Family name(s)

For embassy /consulate use only

2. SURNAME(S) Family Names given at birth

   Date of application :

3. FIRST NAME(S)

   File handled by :

4. DATE OF BIRTH

5. ID CARD NUMBER

6. PLACE AND COUNTRY OF BIRTH

   Supporting documents:

7. NATIONALITY - Present

8. NATIONALITY - Original (at birth)

   □Valid passport

      □Financial means

   □Invitation

   □Means of transport

9. SEX

  □MALE                    □FEMALE

10. MARITAL STATUS

□Single                       □ Separated                 □Widow(er)

□Married                     □Divorced                    □ Other

      □Health insurance

      □Other :

11. FATHER’S NAME

12. MOTHER’S NAME

13. TYPE OF PASSPORT:

þ NATIONAL                       □DIPLOMATIC               □ SERVICE                 □ALIEN’S

□SEAMAN’S                      □TRAVEL DOCUMENT (1951 Convention)

□OTHER TRAVEL DOCUMENT (please specify

………………………………………………………………………… …………………………………..……….…

   Visa :

  □Refused

    □Granted

   Characteristics of Visa :

14. PASSPORT NO.

15. NAME OF ISSUING COUNTRY OR AUTHORITY

  □LTV

    □A

    □B

  □C

16. ISSUED ON

17. VALID UNTIL

    □D

    □D + C

18. If you reside in a country other than your country of origin, have you permission to return to that

     country?

     þ NO/     □ YES     -  Type     ……………….  Valid until............... …………………………………………………..

                                                No …………… Issuing Authority...........………….……………..….

   Number of entries :

  □ 1  □ 2   □ Multiple

   Valid from:

……………………………

*19. TRADE OR PROFESSION

   To:

……………………….……

*20. EMPLOYER AND EMPLOYER’S ADDRESS (For students, name and address of school)

   Valid for :

……………………………...

21. MAIN DESTINATION

         MALTA

22. TYPE OF VISA

  □ Airport transit

  □ Transit

  □  Short stay

  □ Long stay

23. VISA

□  Individual

□ Collective

For embassy / consulate  use only

.

24. NUMBER OF ENTRIES REQUESTED

  □  SINGLE ENTRY

   □  TWO ENTRIES

   □  MULTIPLE ENTRIES

25. DURATION OF STAY

Visa is requested for:   ________days

26. OTHER VISAS (issued during the past three years) AND THEIR PERIOD OF VALIDITY

27. In the case of transit, have you an entry permit for the final country of destination?

   þ NO      □ YES        Type  ……………….  Valid until ……………………………….................................

                                                No ……………........... Issuing Authority …………….........................

*28. Previous stays in Malta

29. PURPOSE OF TRAVEL

□  TOURISM                                                  □  CULTURAL-SPORTS

□  BUSINESS                                                □  OFFICIAL

□  VISIT TO FAMILY or FRIENDS                □ MEDICAL REASONS

□  OTHER (please specify ….…………………………………………………………..........................

*30. DATE OF ARRIVAL

*31. DATE OF DEPARTURE

*32. BORDER OF FIRST ENTRY or transit route

MALTA INTERNATIONAL AIRPORT

*33. INTENDED MEANS OF TRANSPORT

AIR

For embassy / consulate  use only

*34. NAME OF HOST OR COMPANY/ CONTACT PERSON IN MALTA

        If not applicable, give name of Hotel or temporary address.

       NAME

Telephone and Fax

       FULL ADDRESS

e-mail address

*35. WHO IS PAYING FOR YOUR COST OF TRAVELLING AND FOR YOUR COSTS OF LIVING DURING

        YOUR STAY?

  □ MYSELF

  □ HOST PERSON/S

  □ HOST COMPANY

        State who and how and present corresponding documentation

     …………………………………………………………………………………………………………………

*36. MEANS OF SUPPORT during your stay

  þ CASH                  □ TRAVELLERS' CHEQUES       □ CREDIT CARDS

  þTICKETS             þ ACCOMMODATION                  □ OTHER

  □ TRAVEL and/or HEALTH INSURANCE

         (Valid until): …………… ………………………

37. SPOUSE’S FAMILY NAME

38. SPOUSE’S FAMILY NAME given at birth

39. SPOUSE’S FIRST NAME 

40. SPOUSE’S DATE OF BIRTH

41. SPOUSE’S PLACE OF BIRTH

42. CHILDREN  (Applications  must be submitted separately for each passport)

                  NAME                    FIRST NAME                           DATE OF BIRTH                   NATIONALITY

       1

       2

       3

43. PERSONAL DATA OF THE EU CITIZEN YOU DEPEND ON. This question should be answered only

 by family members of EU citizens.

For embassy / consulate  use only

 NAME

 FIRST NAME

 DATE OF BIRTH

 NATIONALITY

 PASSPORT NO.

 FAMILY RELATIONSHIP OF AN EU CITIZEN :

44.

I am aware of and consent to the following: any personal data concerning me which appear on this visa application form will be supplied to the relevant authorities and processed by those authorities, if necessary, for the purposes of a decision on my visa application.  Such data may be input into, and stored in, databases accessible to the relevant authorities.

At my express request, the consular authority processing 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 altered or deleted, in particular, should they be inaccurate, in accordance with the national law of the state concerned.

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.

I undertake to leave the territory upon the expiry of the visa, if granted.

45. APPLICANT’S HOME ADDRESS

46. TELEPHONE NO.

47. PLACE AND  DATE

48. APPLICANT'S SIGNATURE (for minors, signature of

 custodian/guardian)