1. pnilueni/ SURNAME. svobodnyla / STNGLE LJ vdoveca/dova / wrdoweo f 2. OSTATNI JMENA/ OTHER NAMES

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1 Stranal lpagel ZADOST / APPLCATON N O POVOLEN' K TRVALEMU POBYTU / FOR PERMANENT RESDENCE PERMT f] O POVOLEN K DLOUHODOBEMU POBYTU / FOR LONG TERM RESDENCE PERMT fl o prodlouzeni DoBy plarnosl povoleni K DLoUHoDOBEMU pobyru / FoR THE EXTENSoN of valldlry PEROD OF LONG TERM RESDENCE PERMT n o prodlouzeni DoBy platnosr prukazu o povoleni K pobyru pro ctztnce - WwtENu RozHoDNUTi o PoVoLEN K PoBYTU ZA PROKAZ o PoVoLENi K PoBYTU PRo CZNCE / FOR THE EXTENSON OF VALDTY OF THE RESDENT ALEN PERMT - FOR THE SSUE OF A SUBSTTUTE RESDENT ALEN PERMT CARD. EXCHANGE OF A RESDENCE PERMT DECSON FOR A RESDENT ALEN CARD NA UzEMi cesxe REPUBLKY / N THE CZECH REPUBLC ( pozadovan!'oznadte kiiikem / cross the box which applies ) 1. pnilueni/ SURNAME 2. OSTATN JMENA/ OTHER NAMES 3. VSEcHNa onive.si PniUCrui/ ALL PREVOUSURNAMES 4. JMENO(A) / F RST NAME(S) 5. POHLAV / SEX MUZ/ MALE ZeruR FEvTALE 6. DATUM NAROZENT (DDMMRRRR) / DATE OF BRTH(DDMMYYYY) 7. RODNNY STAV / MARTAL STATUS 2rruRrVnroeuA / MARRTED RoZVEDENY/A / DVoRcED 8. STAT NAROZEN(k6d) COUNTRY OF BRTH (code)* 9. MSTO NAROZEN/ PLACE OF BRTH 10. srarni obcanswi (k6d) / NAToNALTY {code)n 11. NEJVYSSi oosnzeue VZDELAN / EDUCATON tl svobodnyla / STNGLE LJ vdoveca/dova / wrdoweo f 12. POVOLAN/ OCCUPATON 13. ZAMESTNAN pneo PRiGHODEM NA OZEM / EMPLOYMENT BEFORE ARRVAL TO THE CZECH REPUBLC ZAMESTNAVATEL EMPLOYER PRACOVNi ZARAZENi / POSTON ULCE / STRFET i. tto. MESTO TOWN ZAMESTNAVATEL / EMPLOYER PRACOVNi ZARAZEN / POSTON PSE / PoST code 14. ZAMESTNANi PO VSTUPU NA UZEM / EMPLOYMENT AFTER ARRVAL TO THE CZECH REPUBLC ULCE / STREET e.ino 15. UEEL PoBYTU NA OzEMi/ PURPOSE OF STAY N THE CZECH REPUBLC PSE / PoST CoDE *) Strana 6 /Page 6

2 Strana2lPage2 16. POSLEDN BYDLSTE V CZNE / LAST RESDENCE ABROAD ULCE / STREET STAT (k6d) i COUNTRY (code)* PSC / POST CODE 17. PREDCHOZ POBYT NA OZEM DELS NEZ 3 MESCE / PREVOUSTAY N THE CZECH REPUBLC LONGER THAN 3/ONTHS POBYT OD / STAY FROM DO /TLL DOVoD A MSTo POBYTU / PURPoSE AND PLACE of STAY ULCE / STREET 19.ADRESA PRO, JE.L DELVERY ADDRESS F DFFERENT FROM RESDENCE ADDRESS ULCE STREET 20. DEN VSTUPU NA UZEM/ DATE OF ARRVAL TO THE CZECH REPUBLC 21. CSLO CESTOVNHO DOKLADU / TRAVEL DOCUMENT NUMBER STAT (k6d)/ COUNTRY (code)* / RESDENCE ADDRESS N THE CZECH REPUBLC 22. PLATNOST CESTOVNHO DOKLADU / TRAVEL DOCUMENT VALD UNTL 23. MANZEL(KA) / SPOUSE pri.vrrui/ SURNAME OSTATN JMENA / OTHER NA[\4ES PSE / POST CODE e./ruo PSE / POST CODE onve.si PRJMENi PREVoUSURNAME JMENO(A) / FrRST NAME(S) STATNi OBCANST-Vi (kod)/ NATTONALTry (code)* DATUM NAROZEN / DATE OF BRTH srar NARozENi (KOD) / country of B RTH {code)* MiSTo NAROZEN PLACE OF BRTH t POVOLAN/ OCCUPATON BYDLSTE / RESDENCE ADDRESS ULCE / STREET STAT (k6d)/ COUNTRY (code)x 24. DET/ chldren PRiJMENi A OSTATN JMENA/ SURNAME AND OTHER NAMES JMENO(A) / e. /No. PSE / POST CODE STATN OBCANSTVT (KOD)/ DATUM NAROZEN / DATE OF BRTH 1 )_. 3. *; Sirana 6 /Page 6

3 Strana3/Page3 25. OTEC / FATHER PR1JMEN/ SURNAME OSTATN JMENA / OTHER NAMES JMENO(A) / FrRST NAME(S) DATUM NAROZENi / DATE OF BRTH sratni OBCANSTV1 (KOD)/ NATTONALTTy (CODE)* POVOLAN/ OCCUPATON * *- BYDLSTE / RESDENCE ADDRESS l: : F : 26. MATKA / MOTHER PRJMENi/ SURNAME OSTATN1 JMENA / OTHER NAMES i F5 JMENO(A) / FrRST NAME(S) DATUM NAROZEN / DATE OF BRTH STATNT OBCANSTV(KOD) / NATTONALTY (CODE)* t; i E l l l ii 3 F rr t * POVOLANi/ OCCUPATON BYDLSTE / RESDENCE ADDRESS 27. SOUROZENC / BROTHERS AND SSTERS PRJMENiA ostatni JMENA / SURNAME AND OTHER NAMES 4 STATNi OBCANSTV (KOD) / POVOLAN / OCCUPATON 28. DOPLNUJiCi NFORMACE / ADDTONAL NFORMATON *; Strana 6 /Page 6

4 Strana4lPage4 29. POUCEN PRO ZADATELE / NSTRUCTONS FOR APPLCANTS 1. Udaje v Zirdosti musi blit vypln6ny strojem nebo hrilkovfm pismem v deskem jazyce.y piipadd nedostatku mlsta v piislusnlch rubrikdch uved'te fdaje na zvl65tni piilohu. 2.Prlva a povinnosti cizinc0, spojena s pobyiem na 0zemieRlsou upravene z6konem 6.326/1999 Sb., o pobytu cizinc0 na r.rzemi eesk6 republiky a o zm6n6 ndkteryich zdkontr, ve zn6ni pozd6j5ich piedpisir., Rizeni o Z6dosti je zah6jeno dnem, kdy do5la v6cn6 a mlstn6 piislu5n6mu spr6vnimu org6nu. Rizeni je upraveno z6konem ( Sb., spr6vni idrd. 3. Osobni 0daje cizince jsou zpracov6v5ny sluzbou cizineck6 a pohranicni policie pro 0dely iizeni dle z6kona d. 326/1999 Sb., a ve stanovenich piipadech Ministerstvem vnitra v souladu se z6konem /2000 Sb., o ochran6 osobnich 0daj0, ve zn6ni pozd6j5ich piedpis0. Rozsah osobnich fdaji, kterytje cizinec povinen uv6st vzddosti dlez6konaa.326/1999sb., stanovi $70odst. ltbhozzakona.dle$159odst. la2zakona e Sb. lze osobni ridaje cizince poskytnout cizinci samotn6mu a d6le tomu, kdo je potiebuje k pln6ni rikol0 stanovenlich z6konem. Cizinec je opr6vndn, pokud zjisti nebo se domniv6, Ze orgdn sluzby cizineck6 a pohranidni policie nebo Ministerstvo vnitra zpracov6v6 jeho osobni ridaje v rozporu se z6konem c. 101/2000 Sb., pozadovat od tohoto org6nu vysvdtleni piipadn6 odstran6ni vznikleho stavu (zejm6na provedeni opravy, dopln6ni nebo likvidaci osobnich ndajn). V piipad6, 2e nebude tomuto pozadavku vyhovdno, m6 cizinec prdvo obr6tit se piimo na Uiad pro ochranu osobnich ldajt. Dle $ 21 odst. 4 zhkona d. 101/2000 Sb. je cizinec opr6vnsn obrdtit se v uveden6 v6ci na Uiad pro ochranu osobnich idaj& i piimo. 1. The answers in this application form must be typed or wriften in block letterslin Czech. lf there is not enough space for any answer, please enclose an addiiional sheet of paper. 2. The rights and duties of aliens residing in the Czech Republic are defined in Act No regulating the residence of aliens in the Czech Republic and amending certain related acts as amended. The proceedings are deemed to be initiated on the date of delivery of the application to the competent authority. The proceeding are regulated'by the Code of Administrative Procedure (Act No. 500/2004). 3. Personal data of aliens are processed by the Alien and Border Police for the purposes of proceedings in terms of Act No and, in specified cases, by the Ministry of the nterior in compliance with Act No. 10'1/2000 regulating the protection of personal data as amended. The range of personal data to be disclosed in this application is defined in Section 70, paragraph 1 of Act No. 326/'1999. According to Section 159, paragraphs 1 and 2 of Act No. 326/1999, an alien's personal data may be released to the alien himself/herself and to authorities that require them for the purpose of tasks set by law. lf the alien finds or believes that the processing of his/her personal data by the Alien and Border Police or by the Ministry of the nterior is inconsistent with Act No. 101/2000, he/she is entitled to request the processing authority to explain or to rectify the situation (in particular to correct, add or destroy personal data). lf the processing authority fails to comply with such reguest, the alien is entitled to seek the assistance of the Personal Data Protection Office, The alien may directly contact thepersonal DataProtectionOfficewithreferencetoSection2l,paragragh 4of ActNo, 101/2000. Svlim podpisem potvrzuji 0plnost a pravdivosi uvedenyich udajfr v Z6dosti/ declare that have answered all questions in this application fully and truthfully Misto / Place Dne / Date Podpis / Signature 30. Zadost piijal a podle dokladt ov6iil: / Application received and documentation checked by Misto / Place... Dne / Date Razitko a podpis / Stamp and Signature

5 Strana5/Page5 31. Prtkaz o povoleni k pobytu pro cizince piedal / Resident Alien Card issued by: : Mlsto / Place... Dne i Date Razftko a podpis vyddvajiciho / Stamp and Signature of issuing Authority 32. PievzetiPrilkazuopovo enikpobytud.:'.'..'..'..,"..' Resident Alien Permit Card No. received by Podpis / Signature

6 Strana6/Page6 ndex of country and territory codes Afghanistan Albania Algeria American Smoa Andorra Angola Arguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet sland ' Brazil British Dependent Territories British ndian Ocean Territory British National (Overseas) British Overseas Territory British Protected Person British Virgin slands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman slands Central African Republic Chad Chile China Christmas sland Cocos (Keeling) slands Colombia Commonwealth of ndependent States Comoros Congo (Democratic Republic of) Congo Cook lslands Costa Rica Cote d'voire t roaila Cuba Lyprus Czech and Slovak Federal Republic Czech Republic Democratic People's Republic of Korea Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Edtrea Estonia Ethiopia European Union Falkland slands (Malvinas) Faroe slands Fiji Finland France French Polynesia French Guyana French Southern Territory Gabon Gambia AFG ALB DZA ASM AND AGO AA ATA ARG ARM ABW AUS AUT AZE BHS BHR BGD BRB BLR BEL BLZ BEN BMU BTN BOL BH BWA BVT BRA GBD OT GBN GBO GBP VGB BRN BGR BFA BD KHM CMR CAN CPV CYM CAF TCD CHL CHN CXR CCK COL SUN COM ZAF. COG COK CR CiV HRV CUB CYP CSK CZE PRK DNK DJ DMA DOM TMP ECU EGY SLV GNQ ER EST ETH XEU FLK FRO FJ FN FRA PYF GUF ATF GAB Gh"B Georgia Germany Ghana Gibraltar Great Brilain Greece { rreenlano Grenada Guadeloupe Guam Guatemala Guernsey Guinea : Guinea-Bissau Guyana Haiti Heard and McDonald slands Honduras Hong Kong Hungary celand ndia ndonesia ran raq lreland sle of Man srael taly Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall slands Martinique Mauritania Mauritius Mavotte Metropolitan France Mexico Micronesia N4onaco Mongolia Montserat Nlorocco Mozambique Myanmar Namibia Nationality not searched out Nauru Nepal Netherlancls Antilles Netherlands Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfo]k Northern Mariana slands Nomay Not established Oland Oman GEO DEU GHA GB GBR GRC GRL GRD GLP GUM GTM XGG GN GNB GUY FT HMD {ND HKG HUN SL.. ND DN RN RQ RL MY SR TA JAM JPN XJE JOR KAZ KEN KR KWT KGZ LAO LVA LBN LSO LBR LBY LE LTU LUX MAC MKD MDG MW MYS MDV ML MLT MHL MTQ MRT MUS MYT FXX MEX FSM MCO MNG MSR MAR MOZ MMR NAM ooo NRU NPL ANT NLD NTZ NCL NZL NC NER NGA NU NFK MNP NOR NNN XFA OMN Pacilic slands Pakistan Palau Palestine Panama Papua-New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatu Queen Maud Land Refugee Republic of Moldova Republic of Korea Rdunion Romania Russian Federation Rwanda Saint Pierre and Miquelon Saint Helena Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia md Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon slands Somalia South Africa South Georgia and South Sandwich lslands Sovereign Order of Malta Spain Sri Lanka St. Vincent and the Grenadines Stateless Sutian Surinam Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan 'fanzania Thailand Togo Tokelau r onga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos slands Tuvalu U.S. slands in the Pacific Ocean Uganda Ukraine United Arab Emirates United States of America United Nations United States Minor Outlying slands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin slands of rhe United States Wailis and Futuna slands Western Sahara Yemen Zambra Zimbabwe PC PAK PLW PSE PAN PNG PRY PER PHL PCN POL PRT PR QAT ATN XXB MDA KOR REU ROM RUS RWA SPM SHN KNA LCA WSM SMR STP SAU SEN SCG SYC SLE SGP SVK S\,N SLB SOM ZAF SGS XMR ESP LKA VCT XXA SDN SUR SJM SWZ SWE CHE SYR TWN TJK TZA THA TGO TKL TON TTO TUN TUR TKM TCA TUV PUS UGA UKR ARE USA UNO tjm URY UZB VUT VAT \.EN VNM VR WLF ESH YEM ZMB ZWE

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