(picture)                                                                                                                         Sticker n.

EMBASSY OF ITALY IN WASHINGTON, DC
Ambasciata d’Italia in Washington DC

APPLICATION FOR ENTRY VISA
Richiesta di visto d’ingresso

(Il presente formulario e’ gratuito. La documentazione presentata ai fini della richiesta del visto non verra’ restituita)
(This form is free of charge and documentation presented for the application will not be returned)

Last name _________________________________Middle Name___________________________________
Cognome

First name ________________________________________________________________ Sex __________
Nome                                                                                                                                                                     Sesso

Father’s Name _______________________ Mother’s Maiden Name ______________________________
Paternità                                                                         Maternità                     (FOR OFFICE USE ONLY)
                                                                                                              
            Data e Numero richiesta

City of Birth __________________ Province of ____________
Nato a                                                         Provincia                                                    Pareri o decisioni

State _______________________ Date of birth ___________            Tipo di visto rilasciato
Stato                                                             Il                     day/month/year

Current Citizenship(s) _______________________________
Cittadinanza(e) attual(i)                                                                                                 /A/ /B/ /C/ /D/

Citizenship at birth___________________________________
Cittadinanza d’origine                                                                                                    /C1/ /C2/ /C3/ /C5/

Marital Status (Stato Civile):                                                                                     INGRESSI /1/ /2/ /M/
Married ______ Single ______ Divorced _____ Widowed______
Coniugato/a             Celibe/Nubile         Divorziato/a             Vedovo/a                         FIRMA ________________________________

Husband/wife name, last name, date and place of birth__________________________________________
Nome, cognome, luogo e data di nascita del coniuge
_________________________________________________________________________________________________________

Children name, last name, place and date of birth (only if they are on your passport and travel with you)
Nome, cognome, luogo e data di nascita dei figli (solo se iscritti sul suo passaporto e viaggiano con lei)
  ___________________________________________________________________________________________________________

Type of passport or Travel Document ____________________________N._________________________
Tipo di passaporto o Documento di Viaggio

Issued by _____________________________On_____________Valid until______________________
Rilasciato da                                                                     il                                   valido al

Green Card n._____________________issued on_______________valid until________________________
Permesso di residenza                                         rilasciato il                                     valido al

Phone and Address in U.S.A. _______________________________________________________________
Indirizzo e telefono in U.S.A.

Occupation _____________________________________________________________________________
Professione

Phone, name and address of employer _______________________________________________________
Telefono, nome ed indirizzo del datore di lavoro

Previous employments_____________________________________________________________________
Precedenti rapporti di lavoro

References in USA________________________________________________________________________
Referenze in USA

Main destination _________________________________________________________________________
Destinazione principale

Border of first entry into the Schengen territory _________________________________________________
Frontiera di primo ingresso nel territorio Schengen

Purpose of stay __________________________________________________________________________
Motivo del soggiorno

Visa requested for: Short stay_________Long Stay__________ Transit ________Airport Transit________
Visto richiesto per     (Less than 90 days)         (More than 90 days)

____1 entry/1 ingresso ___ 2 entries/2 ingressi____ Multiple entry/Ingressi multipli

In case of transit, do you have visa for the country of final destination? YES ______ NO ______
In caso di transito, avete il visto per il paese di destinazione finale?                             Si                       No

Duration of stay for which visa is requested__________________from__________to_______________
Durata del soggiorno richiesto

Name and address of persons in the Schengen States who can provide information
Nome ed indirizzo referenti nell’area Schengen

_______________________________________________________________________________________

Address(es) during your stay in Italy____________________________________________________________
Indirizzo(i) durante il soggiorno

Other Country(ies) you will visit, besides Italy_______________________from______________to__________
Altro(i)Paese(i) di destinazione oltre all’Italia

Date of departure from the U.S.A. ____________________________________________________________
Data di partenza dagli U.S.A.

Date of entry into the Schengen area ___________________________________________________________________
Data di ingresso nell’area Schengen

Italian port of entry and exit _________________________________________________________________
Frontiera d’ingresso e di uscita

Previous trips to Italy or other Schengen Countries (specify)____________________from________to____
Precedenti soggiorni in Italia o in altri Paesi Schengen

Previous visa applications at Italian Foreign Offices___________________________________ and/or
Eventuali precedenti domande di visto

at other Schengen Countries’__________________________________________

I agree in advance to the forwarding of my personal data to the relevant Schengen States’ Authorities, if the same are required for the issuing of a visa.
I declare, to the best of my knowledge, that the supplied data are correct and complete. I am appraised that any false statement will void the application, annul an already granted visa and possibly render me liable to prosecution in accordance with the Schengen States’ laws.
I undertake to leave the territory of the Schengen States upon the expiry of the visa, if granted.
I realize that possession of a visa is only one of the prerequisites for entry into the territory of the Schengen States. If entry is refused I will have no claim to compensation.
I the undersigned declare to have been informed that I must report to the local Police Headquarters (Questura) within 8 (eight) working days from my arrival in Italy in order to receive the permit of stay and on the same occasion I must show proof of Health Insurance for illness, accidents, maternity and, as for long stay permit, I, along with my dependents, can be registered with the national Health Service.

Autorizzo in anticipo - ove necessario - la comunicazione dei miei dati personali alle Autorità dei Paesi Schengen, per la richiesta di visto.
Dichiaro, sotto la mia responsabilità, che i suddetti dati sono corretti e completi e che ogni mendace dichiarazione può condurre al rigetto o annullamento del visto già rilasciato nonché al possibile procedimento giudiziario in base alle leggi degli Stati Schengen.
Mi impegno a lasciare il territorio Schengen alla data di scadenza del visto, se concesso.
Sono stato messo al corrente del fatto che il possesso del visto è soltanto uno dei requisiti per l’ingresso nel territorio Schengen e che, ove l’ingresso venga rifiutato, non potrò chiedere risarcimenti.
Il sottoscritto dichiara di essere a conoscenza dell’obbligo di richiedere il permesso di soggiorno alla Questura competente entro 8 (otto) giorni lavorativi dal suo ingresso in Italia, e dell’obbligo di assicurarsi contro il rischio di malattie, infortuni e maternita’, mediante stipula di apposita Polizza Assicurativa o iscrizione al Servizio Sanitario Nazionale (valida anche per i familiari a carico).

Date ______________________     _______________________________________
D
ata                                                           Signature (in case of minor of the legal guardian)
  
                                                Firma (se minore del legale rappresentante)

ANNOTAZIONI (riservato all’Ufficio)
_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Data                                                                                 Firma dell’addetto alla ricezione

ESITO:__________________________________________________________________________________________________

________________________________________________________________________________________________________

                                                                                        Firma dell’addetto