ZAHTJEV ZA AZIL ASYLUM APPLICATION

Transcription

1 Obrazac popunite Ëitljivo This form should be filled in clearly Naziv tijela kojemu se zahtjev podnosi of the authority which the application is submitted to OBRAZAC 1 FORM 1 PRIJAMNI PE»AT RECEIVING SEAL ZAHTJEV ZA AZIL ASYLUM APPLICATION I. OSOBNI PODACI TRAÆITELJA AZILA I. ASYLUM SEEKER S PERSONAL DETAILS 1. Prijaπnje prezime Former surname Nadimak Nickname 2. (dan, mjesec i godina) (day, month and year) 3. Spol muπki Sex male 4. Mjesto i dræava roappleenja Place and state of birth 5. Dræavljanstvo Citizenship 6. Materinski jezik Mother tongue Drugi jezici koje razumijete Other languages you understand 7. Narodnost Nationality 8. Plemenska pripadnost Tribe affiliation 9. Vjera / religijska pripadnost Religion / religious affiliation 10. Zadnje prebivaliπte i adresa stanovanja u zemlji podrijetla Last permanent residence and residence address in the country of origin 11. S kime ste æivjeli u zajedniëkom domaêinstvu u zemlji podrijetla? Who did you live with in the common household in the country of origin? / / / Srodstvo / Kinship / / / Srodstvo / Kinship Ostali (navedite samo srodstvo) Others (specify only kinship) 1

2 12. Zvanje i zanimanje: Vocation and occupation: a) Bez πkole Without any school b) Osnovna πkola (od/do, godina) mjesto Elementary school (from / to, year) place c) Srednja πkola (od/do, godina) mjesto Secondary school (from / to, year) place d) Fakultetsko obrazovanje (od/do, godina) mjesto University education (from / to, year) place ustanove of the institution e) Vrsta teëaja (od/do, godina) mjesto Type of course (from / to, year) place f) g) Upiπite podatke o posljednjem zaposlenju: Fill in the details about the last employment: Naziv poslodavca of employer Vrsta posla Sort of work Od / do From / to Mjesto i adresa Place and address h) Nikad nisam bio zaposlen I have never been employed II. VOJNA OBVEZA II. MILITARY CONSCRIPTION 13. Jeste li sluæili vojnu obvezu? da ne Have you done the military service? yes no 14. Ako niste sluæili vojnu obvezu, obrazloæite zaπto! If you have not done the military service, specify the reasons for it! 15. Ako ste sluæili vojnu obvezu, navedite: If you have done the military service, specify: a) Gdje i kada Where and when b) Vojni sastav Military structure c) Vojni Ëin Military rank d) Je li vaπa vojna obveza potpuno zavrπena: da Has your military service been completely fulfilled: yes ne no 2

3 III. OBITELJSKI I DRUGI ODNOSI III. FAMILY AND OTHER RELATIONSHIPS 16. BraËno stanje: Marital status: nevjenëan/a zaruëen/a vjenëan/a unmarried engaged married vjenëan/a, ali ne æivimo skupa izvanbraëna zajednica married, but we do not live together common-law marriage razveden/a udovac/ica divorced widower/widow 17. Navedite podatke o osobi iz toëke 16: Specify the details of the person from item 16: Ranije prezime Former surname 18. Upiπite traæene podatke o djeci poëevπi od najstarijeg: Specify the required details on children, starting from the eldest: Koliko imate djece? Nemam djece. How many children do you have? I have no children. Spol muπki Spol muπki Sex male Sex male Dijete obuhvaêeno zahtjevom: Dijete obuhvaêeno zahtjevom: Child comprised by application: Child comprised by application: da / yes da / yes ne / no ne / no Spol muπki Spol muπki Sex male Sex male Dijete obuhvaêeno zahtjevom: Dijete obuhvaêeno zahtjevom: Child comprised by application: Child comprised by application: da / yes da / yes ne / no ne / no 3

4 Ostali (navedite samo imena i datume roappleenja) Others (specify only their names and dates of birth) 19. Podaci o roditeljima: Details on parents: a) otac æiv preminuo father alive deceased Ranije prezime Former surname b) majka æiva preminula mother alive deceased Ranije prezime Former surname 20. Upiπite traæene podatke o braêi i sestrama poëevπi od najstarijeg: Specify the required details on brothers and sisters, starting from the eldest: Koliko imate braêe i sestara? Nemam braêe i sestara. How many brothers and sisters do you have? I do not have any brothers or sisters. BraËno stanje BraËno stanje Marital status Marital status Spol muπki Spol muπki Sex male Sex male 4

5 BraËno stanje Marital status BraËno stanje Marital status Spol muπki Spol muπki Sex male Sex male Ostali (navedite samo imena i godine roappleenja): Others (specify only their names and years of birth): 21. Podaci o srodnicima u Republici Hrvatskoj: Details on relatives in the Republic of Croatia: Imam srodnika/e u Republici Hrvatskoj. I have relatives in the Republic of Croatia. Srodstvo Kinship Status u RH Status in RC Nemam srodnika/e u Republici Hrvatskoj. I do not have any relatives in the Republic of Croatia. Srodstvo Kinship Status u RH Status in RC Spol muπki Spol muπki Sex male Sex male Adresa Address Broj telefona Telephone number Adresa Address Broj telefona Telephone number 5

6 22. Podaci o poznanicima u Republici Hrvatskoj: Details on acquaintances in the Republic of Croatia: Imam poznanika/e u Republici Hrvatskoj. I have acquaintance/s in the Republic of Croatia. Adresa Address Broj telefona Telephone number Nemam poznanika/e u Republici Hrvatskoj. I do not have any acquaintance/s in the Republic of Croatia. Adresa Address Broj telefona Telephone number 23.»lanovi obitelji s kojima ste doπli u Republiku Hrvatsku: Family members whom you have come to the Republic of Croatia with: Srodstvo Kinship Srodstvo Kinship Ostali (navedite samo imena i srodstvo) Others (specify only their names and kinship) U Republiku Hrvatsku nisam doπao ni s jednim Ëlanom moje obitelji. I have come to the Republic of Croatia without a single member of my family. 24. Ostale osobe s kojima ste zajedno doπli u Republiku Hrvatsku (osim navedenih u toëki 23): Other persons whom you have come to the Republic of Croatia with (except the mentioned in item 23): Gdje i kada ste se upoznali? Where and when did you meet each other? Gdje i kada ste se upoznali? Where and when did you meet each other? U Republiku Hrvatsku sam uπao sam. I have entered the Republic of Croatia alone. U Republiku Hrvatsku uπao sam s osobama Ëija toëna imena ne znam. I have entered the Republic of Croatia with the persons whose accurate names I do not know. 6

7 25.»lanovi obitelji koji æive izvan Vaπe zemlje podrijetla: Family members who live outside your country of origin: Spol muπki Spol muπki Sex male Sex male Srodstvo Kinship Dræava u kojoj boravi Country which he/she resides at Datum ulaska Date of entry Status u kojem boravi Status in which he/she resides Srodstvo Kinship Dræava u kojoj boravi Country which he/she resides at Datum ulaska Date of entry Status u kojem boravi Status in which he/she resides Nemam Ëlanova obitelji koji æive izvan moje zemlje podrijetla. I do not have any family members who live outside my country of origin. IV. RAZLOZI NAPU TANJA ZEMLJE PODRIJETLA IV. REASONS FOR LEAVING THE COUNTRY OF ORIGIN 26. Jeste li napustili zemlju iz ekonomskih razloga? DA NE Have you left the country for economic reasons? YES NO Obrazloæite! Explain! 27. Razlozi napuπtanja zemlje podrijetla (jeste li bili πikanirani, tuæeni, pritvarani, podvrgnuti torturi ili vam je mjesto boravka bilo pretresano i sliëno). Navedite datum i mjesto dogaappleaja, nadleæno dræavno ili drugo tijelo koje je sudjelovalo u dogaappleaju? Reasons for leaving the country of origin (you were harassed, prosecuted, arrested, exposed to torture or your place of residence was searched and similar). Specify date and place of the event, competent state or other authority which participated in the event! 7

8 28. Jeste li ikada bili kaænjavani? DA NE Have you ever been punished? YES NO Vrsta i visina kazne Type and amount of punishment novëana penalty zatvorska prison neka druga kazna / koja some other punishment/which one Naziv i sjediπte tijela koje je kaznu izreklo and headquarters of the authority which determined the punishment naziv tijela name of the authority sjediπte headquarters Za koje djelo vam je izreëena kazna? Which offense were you punished for? Jeste li kaznu odsluæili? Have you served out the punishment? DA YES u potpunosti completely NE NO djelomiëno partially ostatak kazne rest of the punishment 29. Jeste li pripadnik kakve politiëke stranke ili druge organizacije (npr. religiozne, sindikalne)? Are you member of any political party or other organization (for example, religious organization, labor-union) DA YES NE NO Naziv i sjediπte organizacije and headquarters of the organization Od kada ste Ëlan Membership since 30. to smatrate da bi Vam se dogodilo ako se vratite u dræavu podrijetla? Obrazloæite! What do you think could happen to you if you return to the country of origin? Explain! 8

9 V. NA»IN ODLASKA IZ ZEMLJE PODRIJETLA V. WAY OF LEAVING THE COUNTRY OF ORIGIN 31. Upiπite datum odlaska iz zemlje podrijetla (dan, mjesec i godina) Fill in the date of leaving the country of origin (day, month and year) 32. Opiπite detaljno odlazak iz zemlje podrijetla (kada, gdje, kako): Describe in details your leaving the country of origin (when, where, how): 33. Koju ste ispravu pri odlasku iz zemlje podrijetla imali sa sobom: Which document did you have with you when leaving the country of origin: putnu ispravu travel document bez putne isprave without a travel document krivotvorenu putnu ispravu forged travel document neku drugu ispravu / koju another document / which one 34. Jeste li ikada prije u Republici Hrvatskoj podnosili zahtjev za priznavanje azila? Have you ever applied for asylum in the Republic of Croatia so far? DA NE Kada? YES NO When? 35. Jeste li ikada prije podnosili zahtjev za priznavanje azila u nekoj drugoj dræavi? Have you ever applied for asylum in another state? DA NE Gdje? YES NO Where? Kada? When? 9

10 36. Dræava/e, grad/ovi u kojima ste boravili, odnosno kroz koje ste proputovali nakon πto ste napustili zemlju podrijetla: State/s, city/ies which you stayed at, i.e. which you travelled through after leaving the country of origin: Dræava / grad State / city Vremensko razdoblje Time period 37. Datum ulaska u Republiku Hrvatsku (dan, mjesec i godina) Date of entry into the Republic of Croatia (day, month, year) 38. Mjesto ulaska Place of entry 39. NaËin ulaska Way of entry: a) legalno legally ilegalno illegally b) kopno more zrak land sea air pjeπice on foot autom by car kamionom by truck vlakom by train drugi naëin another way 40. Posjedujete li dokumente za utvrappleivanje identiteta: Do you have any documents for establishing identity: Posjedujem dokumente. I possess documents. Ne posjedujem dokumente. I don t possess any documents. a) Vrsta dokumenta Type of document broj izdan u datum vrijedi do number issued at date expiry date b) Vrsta dokumenta Type of document broj izdan u datum vrijedi do number issued at date expiry date 10

11 41. Jeste li ikad prije bili u Republici Hrvatskoj? Have you ever been to the Republic of Croatia (so far)? DA YES NE NO Kada? When? 42. Posjedujete li novëana sredstva za uzdræavanje u Republici Hrvatskoj? Do you have any financial resources for maintenance in the Republic of Croatia? DA NE Valuta Koliko? YES NO Currency How much? 43. Imate li kakvih zdravstvenih problema? Do you have any health problems? 44. Zavrπna izjava: Final statement: a) Ovim potvrappleujem da su svi podaci koje sam iznio u zahtjevu toëni te sam spreman snositi materijalnu i kaznenu odgovornost u sluëaju davanja netoënih podataka. By this, I am confirming that all the details I have specified in this application are accurate, and I am ready to bear material and criminal responsibility in the case of presenting false details. DA YES NE NO c) Primio sam pisane upute za ispunjavanje zahtjeva za azil, te o svojim pravima i obvezama u postupku i iste sam razumio. I have received the written instructions for filling in the asylum application, as well as the instructions on my rights and obligations in the procedure, and I have understood them. DA YES NE NO U, dana In date Potpis podnositelja zahtjeva Signature of asylum applicant, ime i potpis skrbnika/ zakonskog zastupnika, name and signature of guardian/legal representative 11

12 fotografija photograph 30x35 mm fotografija photograph 30x35 mm fotografija photograph 30x35 mm, ime i potpis prevoditelja, name and signature of interpreter Potpis sluæbene osobe Signature of official Popunjava sluæbena osoba kojoj je zahtjev podnesen: Filled in by the official whom the application has been submitted to: Ishod postupka: Result of the procedure: Broj i datum rjeπenja: Number and date of the formal decision: Datum uruëenja stranci: Date of its delivery to asylum applicant: Potpis sluæbene osobe Signature of official 12