iscp r. rnoroRazltko uladu / Stamp of Embassy or Consulate

?adosto ud6leni dlouhodobdho vizaTe n t o formul 4I j e z d arm a

Application for long-stay visaThis applicatioa form is free ofchatge

l\

" ' '.: i :t.Vi :l:ffi g*g lil-l:,;

5. Mlsto narozeni / Place of birthlfri r-ir..i,rinti i\li=it:iti i i i I i I : i I I i i : i i ! I i i i i

Stit narozeni (k6d) / Country of birth (code) -DfkDrtG q Gt-td E I t'' Ll ri

Stritnl obdanstvl pii narozen{ (k6d) / Original nationaliry (nationality at birth) (code)

Soudasnd st{tnI obdanswl (k6d) / Current nationality(ies) (code))

:-r: I i: t/:i...\..:..s.\1..H

N]!rY€T1.....i2""" I r"-,r" i4 f\\ f\t\

DL(LrtlLl Lil) t t1t-t.-

7.

DanrmpodCn{:

DopLluj{cldokunenty

r t'{

Platnf pas

Prostledky k pobytu

Doklad o ubytovdni

Doklad o trestnizachovalosti

domovsk€ho stdtu ($

174 zSkona

d.326/1999 Sb.)

Ldkaiskri zpriva ($ 31

odst. 5 pism. b)zrikona t. 326/1999

Pozvdni

Dopravnlprostiedky

Zdravotni pojiitEni

Doklad powrzujiciridel pobltu

Dalii:

StH\,:> 1

Dt tti.:-r i \ol-]o,r]{'iFl r{

Hut!t,,\rt 17 rt: ft i'Ctl t1951) / Travel document (1951 Convention)

1954) / Travel document (1954 Convention)

Dr-i,lt r:

15. Danrm vystaveDl (ddmmrrrr) / Date of issue (ddmmyyyy),v' 1 ; > 11 1-'1 g ' i

\'lt''l iiPlatnf do (ddmmrrrr) / Validuntil (ddmmyyyy),.)p1-.;rt'. t. . p,' t *

r.....r......r..1,r...Lr....-..,.:.ij',.........,..*

i\ illir..: t:T1 i! i i i,.,'.,,'.'....'...''... ;:'-i"';'i". )i""":":' ,':' . "i""'i""'i:i:A:.L.:l:l-l:r:::i.,L.,;.,1.1.i..:..;..'....i.:..r.:.....i...,..i...,,;

Proflednirllely

For Official Use Only

16.Straaa/ Page I

17.

[L\,_ti,?,!!:.-.t Uja-p]i !tv OA air- [*r;ei,li (-iL,r_gr.cr. i:rri,Ula ,"- r,]Zrr you reslge 11 a coultq offrer than your country o1- origip.hawe. you permission to returnlo that

]esdile se zdrlujete v jin€ neZ domovsk€ zemi, uvedte opnivnEn{ k n{vratu pro zemi byilliit6.O-CF ro

country? i':€.c, GLt'-c\g Oc,fvi"ii:, i".r.r .vifti.:- tTtf rt\i?:""'i*"/Nortft{ {['.

Druhv{za"

Previous stay iu Czech Republic longer than 3 months

Address for stay on tle territory of the Czech Republic r-*€f- L L,|.-tt'\"' De fAlt t" A t f1r<- Kt\

Platndpro:

25. Piedpoklddan{dobapobyru/Visaisrequestedlorft}e\<{"SG{4ts!.Gi'.ri'i\ja'iza"y,

-fltfg.[k,14.)./. country (code): L:T,: I,I:i.,...:.Y;..:.:

:,.,,.:....,i.....:

Platn6 od:

(s€

Pro rllednl rldely

For OfficialUse Onlv

26. Ptedchoz{viza (ud€lend Ceskou republikou v posledn{ch tiech letech) a jejich platnost

Strana/ Page 2

:t i

35.

28. Udelpobyft/Purposeofstay Cfrtt 5 5€ &€Ar

B,€rJ

-ir Nt.}

31. M{sto na rlzem{ Ceskd {.P-l*S:..9.r-.S*gyi*tt'S"._c""_r""..*

/ Meens ofLi/*! -sr iali if\i Lr'\!.-ii ;( ii ifu;tri l:L: t i /i (i-ti \i :

2e. Datum zamfslencho pfijezdu (ddmmrrrr) / Date of arriv"Jiftr gr, is:..i*. ffi.i,.rJi.*'..'.i.

",,,.,.;30. Datum zamfslendho odjezdu (ddmmrrrr) / Date of deparrure (ddrnpyyyy)

i,..:*.Ar.,i.,,4..,;"::.$:...i_: :.,..i..--.....:

t_

,e'll-r -r-T{C lr\f\

c€Zvouc{ prdvnickd nebo fyzickt osoba / Inviting legal or natural person O"r1 t-e*C trLlt1 Kigi]mdno a pHjmeni osoby / Name and sumame of the person

Ulice / Street

Pro $tednlrllely

For Official Use Only

MEsto / Town

PSE / ZIPi?-il-".i{"i;;]!-:-i*-*i-i-.i.-..:..i.I...1...i

34. Zprisob zaji5tEnl rihrady n{kladri spojenfch s pobyrem \Mannerof tundi'gthe stay{.ftt-i S riv F if.- Aru\t 'Lo,l*X} .$t=r ui'I "iZ"a"ors6m/Myself

C-g N Dii\-{i----: -1,,,....iZvouci fyzickd osoba(y) / Host person(s) f\(r { A\-

i *--:

i."...,...i2"o".i prdvnickd osoba / Host.o-p"tyli ( f 2 Lflr1filt,{- l1-r i rf}Uvedte odpovidajicf doklady / Presenr corresponding documenration i-L tr i'r i* Prt i tr{"

Finandn{ prostledky k tivobyt{ po dobu pobyru / *:"n of rlnng.t *:"g {o:t *"y L,€\ u. r g 5 Ji:::;

!Q911{f, ( t.st

r/LCr:---'!i iFinandni hotovost / Cash lV.A Lr '{

i'i ipt",uu"i karty / credit cards !( Ae O i t A € 't I

i ;S"U, (cestovni)/ Traveller's cheques \t tltr+ti /\ t {+f f ,'!

'iorr"tni/other rfr@f l-

rt"lft s I'ir\i: L ft dL\ f\-, u-ft t r{r riif ,S !

Dai-9xt"lltsp.si*5:iF".:l"p"i:.,.*-""*J:.*."""."*Iy"::.:::i).{"9,fr *

i at LV,rtiar ir,",'t ilo-ru" a tpecify, e.g. certificate of accommod'ation).:'---.i.-..!...''i.-'.''.:....,....'.!'.',''.'...1"-.'""i.

sC:.u€5rue

iiii ii

1

" ', co.orrt a/nebo zdravotni pojiitEni / Travel and./or healrh insuranc".S€1-{ {:t{ A\ 1f 7

t"'t- l ft>rtrlcr r \ )bL f-'t'-4'-{ J

platn6 do (ddmmrrrr) / valid un-til (ddmrslyly) ^ _ _ L :--i-i*i- i^|.:::j...

,..,i....,, :t:-pf e ' i..C t-'-t t l( -\r'rfl C Sr : """ ;"""""';" """;" "'i"""" i'

. trl\i ",J

Strana/ Page 3

t,

b.

Stdtni obdanstvi manielky (k6d) /Spouse's nationality (code) f.--,fp Jt t q .f O(:) L,l

37. DEti (pro kaidou osobu musi byt podrina samostarnd iridost) L rra t-t t, trlrZchildren (Applications must be submitted separately for each passport) r€p-- t f\:r\('cd s't7- rLj.ri;.irtutAt

t""'1""'i""'i""'t""'t"""i""'i""'ii......i,....i......:......i.....!......i.....;...,.i

d.

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ForOftcirl gss go1,

r(1 |

iAy at "ftSA

Strana/ Page4

1. Udaje v iidosti musi bjt rypln6ny strojem nebo htlkovfm pismem v desk6m 1'azyce. V piipad6 nedostatku mista v piisluiny'ch rubrikdch

uvedte ridaje na zvl6itni pfilohu.

2.Prdvaapovinnosticizincri,spojen6spobytemna(zemiCRlrouupravendzdkonem t.326/1999Sb.,opobytucizincrina(zemiCeskdrepubliky a o zm€nE ndkterych z6kont, ve zn6ni pozddjiich piedpisti'

3.Osobniridajeproudelyiizenipodlezdkonat.32611999Sb.,jsouzpracovdvdnysluiboucizineck6policie, avestanovenlichpiipadech

Ministerswem vnitra v souladu se zdkonem d. 101/2000 Sb., o ochrand osobnich tdajri, ve znEni pozd€jiich pfedpisri.

4. V souvislosti s Zddosti o dlouhodobd vizum jsem povinen na poi6drini strpdt sejmuti otiskt prstt a poiizeni obrazovdho zAznamtt.

5. Zavazttji se opustit fzemi Cesk6 republiky pied skondenim doby povolen6ho pobytu na fzemi Cesk6 republiky.

6. Byl jsem informovdn o skutetnosti, ie ud€leni viza je jen jednou z podminek vstupu na rizemi Ceskd republiky. Pouhri skutednost, Ze mi bylouddleno vizum, neznamen6, ie mfm pr6vo na n6hradu 5kody, pokud z drivodri nesplndni podminek vstupu a pobycu na uzemi Cesk6

republiky stanovenlich zdkonem d. 326/1999 Sb., mi bude vstup na rizemi Ceskd republiky odepien.

7. Byl jsem informoviin, Ze jsem povinen do 3 pracovnich dnri ode dne vstupu na rizemi ohl6sit na policii Ceskd republiky misto pobytu na

rizemi Cesk6 republiky.

8. Prohlaiuji, ie jsem vSechny vjie uvedend ridal'e poskytl(a) podle svdho nejlepiiho v6domi a svEdomi a ie jsou sprdvn€ a ripln6.

1. Details in the Application must be completed in block letters in the Czech language. If more space is needed, specify the details in a special

enclosure.

2. Rights and duties ofaliens connected with their stay on the territory ofthe Czech Republic are governed by Act no. 326/1999 Coll.,

regulating Residence of Alliens in the Territory of the Czech Republic and on changes of some acts, as amended.

3. Personal details for the purpose ofproceedings pursuant to Act no. 32611999 Coll. are processed by the foreign police service and by Ministryof Interior in specified cases pursuant to Act no. 101/2000 Coll. regulating personal data protection as amended.

4. In relation to the Application for a long-term visa, I am obliged to suffer fingerprinting and taking ofvisual image on request.

5. I hereby undertake to leave the Czech Republic before the termination of my permitted stay on the territory of the Czech Republic.

6. I have been informed about the fact that granting a visa is only one of the conditions for entering the Czech Republic. The mere fact that Ihave been granted a visa does not mean that I am entitled to damages in case that I am prevented from entering the Czech Republic based onmy failure to meet conditions for entry and stay in the Czech Republic specified in Act no. 32617999 ColI.

7. I have been informed that I am obliged to report the place of stay in the Czech Republic to the Czech Police within 3 business days followingmy€ntry. I

8. I h{reby represent that I have provided all the above specified details according to my true and free will and that they are complete andcodrect.

adatun: ar,- 1 _._\,\anddate: lC!-. \C ({\-tt-]

Podpis ladatele ( u nezletiljch podpis zrikonndho z:istupce):

Applicant's Signature (for minors, signature of custodian/guardian):

Flr-r ?+

tf

Misto pro nalepeni kontroini d:isti vfzovdho Stitku

Podpis pracovnika vyddvajiciho vizum

Strana/ Page 5