APPLICATION FOR INTERNATIONAL PROTECTION

The application should be filled in Polish language

I am submitting this application also on behalf of

a) my spouse  info_outline
b) my minor children  info_outline

PART I

DATA AND INFORMATION CONCERNING THE APPLICANT AND THE PERSONS ON BEHALF OF WHOM THE APPLICANT IS ACTING AND THE GUARDIAN/REPRESENTATIVE OF AN INTERNATIONAL OR NON-GOVERNMENTAL ORGANISATION WHO IS SUBMITTING THE APPLICATION ON BEHALF OF THE UNACCOMPANIED MINOR

A. APPLICANT'S DATA AND INFORMATION

1. Name (names) and surname in the mother tongue  info_outline
* field is required
2. Surname  info_outline
* field is required
3. Family name  info_outline
* field is required
4. Name (names)  info_outline
* field is required
5. Other previously used surnames  info_outline
6. Father's name  info_outline
* field is required
7. Mother's name and maiden name  info_outline
* field is required
8. Date of birth or age  info_outline
9. Sex  info_outline
* field is required
10. Place of birth
a) country  info_outline
* field is required
b) region (province)  info_outline
* field is required
c) town (city)  info_outline
* field is required
11. Description 
a) height  info_outline
* field is required
b) colour of eyes  info_outline
* field is required
c) special marks  info_outline
* field is required
12. Citizenship (citizenships)  info_outline
* field is required
13. Nationality  info_outline
* field is required
14. Race or ethnic origin  info_outline
* field is required
15. Religious affiliation  info_outline
* field is required
16. Marital status  info_outline
* field is required
17. Country of origin  info_outline
* field is required
18. Last place of residence in the country of origin 
a) region (province)  info_outline
b) town (city)  info_outline
c) period from  info_outline
period to  info_outline
19. Education  info_outline
* field is required
How many years did you attend school?  info_outline
* field is required
20. Last place of employment in the country of origin 
a) place  info_outline
b) name of the employer  info_outline
c) period from  info_outline
period to  info_outline
21. Did you serve in the military in the country of origin?  info_outline
* field is required
Please state the period and place of the military service and the name of the military unit 
22. Knowledge of languages 
a) mother tongue 
* field is required
b) other (applies to the languages, in which the applicant is able to communicate naturally) 
23. In which language(s) would you like to be interveiewed in the proceedings concerning international protection?  info_outline

B. DATA ON GUARDIAN/REPRESENTATIVE OF AN INTERNATIONAL OR NON-GOVERNMENTAL ORGANISATION WHO IS SUBMITTING THE APPLICATION ON BEHALF OF THE UNACCOMPANIED MINOR

1. Surname  info_outline
2. Name (names)  info_outline
3. The name of the organisation you represent  info_outline
4. Date and file number of the court decision on the appointment of a guardian  info_outline
5. Mailing address
a) town (city)  info_outline
b) street  info_outline
c) house number  info_outline
d) apartment number  info_outline
e) postal code  info_outline

C. APPLICANT'S DATA AND INFORMATION

a) wife / husband  info_outline
b) Name (names) and surname in the mother tongue  info_outline
c) Surname  info_outline
d) Family name  info_outline
e) Name (names)  info_outline
f) Other previously used surnames  info_outline
g) Father's name  info_outline
h) Mother's name and maiden name  info_outline
i) Date of birth or age  info_outline
j) Place of birth
- country  info_outline
- region (province)  info_outline
- town (city)  info_outline
k) Description 
- height  info_outline
- colour of eyes  info_outline
- special marks  info_outline
l) Citizenship (citizenships)  info_outline
m) Nationality  info_outline
n) Race or ethnic origin  info_outline
o) Country of origin  info_outline
p). Religious affiliation  info_outline
r) documents of identity  info_outline
s) Knowledge of languages 
- mother tongue 
- others (it applies to the languages in which the applicant’s spouse is able to communicate naturally) 

2. Data on the minor children on behalf of whom the applicant is acting

1:

Name 
Surname 
Date of birth 
Sex 
Names of the parents – it does not apply to an application covering both parents 

2:

Name 
Surname 
Date of birth 
Sex 
Names of the parents – it does not apply to an application covering both parents 

3:

Name 
Surname 
Date of birth 
Sex 
Names of the parents – it does not apply to an application covering both parents 

4:

Name 
Surname 
Date of birth 
Sex 
Names of the parents – it does not apply to an application covering both parents 

5:

Name 
Surname 
Date of birth 
Sex 
Names of the parents – it does not apply to an application covering both parents 

PART II

A. INFORMATION CONCERNING THE DEPARTURE FROM THE COUNTRY OF ORIGIN BY THE APPLICANT AND THE PERSONS ON BEHALF OF WHOM THE APPLICANT IS ACTING

1. Date of departure  info_outline
2. Method of departure  info_outline
* field is required
3. Name of the place of crossing the border of the country of origin  info_outline
4. Mean of transportation used to cross the border of the country of origin  info_outline
5. Document entitling to leave the country of origin  info_outline
6. If there were any problems while crossing the border of the country of origin, please provide details  info_outline
7. Has anyone taken identity documents from you or from the persons on behalf of whom you are acting?  info_outline
* field is required
Please describe the situation, when the identity documents were taken, from whom and by whom they were taken and for what purpose 
8. Did you or any persons on behalf of whom you are acting leave the country of origin within the last 5 years?  info_outline
* field is required
Please state who left, for how long, to which country and for what purpose 
9. Did authorities of any other country issue visas or residence permits to you or to the persons on behalf of whom you are acting?  info_outline
* field is required
Please state, who they were issued for, when, by whom and what document it was 

B. INFORMATION CONCERNING THE ENTRY AND STAY OF THE APPLICANT AND THE PERSONS ON BEHALF OF WHOM THE APPLICANT IS ACTING ON THE TERRITORY OF THE REPUBLIC OF POLAND PRIOR TO SUBMISSION OF THE APPLICATION

1. Information concerning the last entry on the territory of the Republic of Poland

a) country of the last stay after leaving the country of origin, including the nature and purpose of the stay  info_outline
b) transit countries  info_outline
c) means of transportation used during the journey to the Republic of Poland  info_outline
d) date of entry  info_outline
e) place of entry  info_outline
f) method of entry  info_outline
* field is required
g) document entitling to the entry on the territory of the Republic of Poland  info_outline

2. Information concerning the stay on the territory of the Republic of Poland

a) Have you or has any person on behalf of whom you are acting stayed on the territory of the Republic of Poland within the last 5 years?  info_outline
* field is required
Please state the period and the purpose of stay for each person included in this application 
b) Have you ever been issued any decisions on imposing the return obligation from the territory of the Republic of Poland or any other European Union Member State?  info_outline
* field is required
c) Is your current stay on the territory of the Republic of Poland or the current stay of the persons on behalf of whom you are acting legal?  info_outline
* field is required
Please specify the basis of the stay (visa, temporary residence permit, permission to stay for humanitarian reasons, tolerated stay permit, other) for each person included in this application 
Please state the date as of which the stay on the territory of the Republic of Poland is illegal for each person included in this application 
d) The current or declared place of residence on the territory of the Republic of Poland  info_outline
town (city)  info_outline
street  info_outline
house number  info_outline
apartment number  info_outline
postal code  info_outline
Type of the place of residence (private apartment, hotel, student's hostel)  info_outline
mailing address (if other than mentioned above)
town (city)  info_outline
street  info_outline
house number  info_outline
apartment number  info_outline
postal code  info_outline

3. Identity documents issued by the authorities of the Republic of Poland

a) residence card  info_outline
Document's series  info_outline
Document's number  info_outline
Document's date of issue  info_outline
Document's expiry date  info_outline
Document's issuing authority  info_outline
b) other documents confirming the identity 
c)  

PART III

INFORMATION CONCERNING HEALTH CONDITION AND VIOLENCE SUFFERED BY THE APPLICANT AND THE PERSONS ON BEHALF OF WHOM THE APPLICANT IS ACTING

1. Do you or any person on behalf of whom you are acting have any health related problems?  info_outline
* field is required
Please indicate that person and describe what health problem he/she has 
2. Are you or is any person on behalf of whom you are acting disabled?  info_outline
* field is required
Please indicate that person and define the type and level of disability 
3. Are you or is any person on behalf of whom you are acting pregnant?  info_outline
* field is required
Please state who 
4. Have you or has any person on behalf of whom you are acting ever experienced physical violence, including acts of sexual violence, as well as caused by gender, sexual orientation or gender identity?  info_outline
* field is required
Please state who it was and describe all the circumstances related to the experienced violence (who the perpetrator/perpetrators was/were, when and where it happened, what the reason of the violence was and any other relevant facts) 
5. Have you or has any person on behalf of whom you are acting ever experienced psychological violence, including acts of sexual violence, as well as caused by gender, sexual orientation or gender identity? Have you or has anyone who is close to you experienced a life- or health-threatening event?  info_outline
* field is required
Please state who it was and describe all the circumstances related to the experienced violence (who the perpetrator/perpetrators was/were, when and where it happened, what the reason of the violence was and any other relevant facts) 

PART IV

REASONS FOR APPLYING FOR INTERNATIONAL PROTECTION BY THE APPLICANT AND THE PERSONS ON BEHALF OF WHOM THE APPLICANT IS ACTING

1. Please state, using any number of additional sheets, reasons for applying for international protection. Please provide all the important information concerning, inter alia, race, nationality or ethnic background, religion, membership in the particular social group or political views of yourself and the persons on behalf of whom you are acting 
2. Are you or any person on behalf of whom you are acting afraid of returning to the country of origin?  info_outline
* field is required
Please state who is afraid of whom and what 
3. Are the authorities of your country of origin capable of protecting you or the persons on behalf of whom you are acting in case of returning to the country of orgin?  info_outline
* field is required
Please explain 
4. Was there or is there still a chance to find protection in another part of your country of origin?  info_outline
* field is required
Please explain 
5. Have you or has any member of your family ever been detained or arrested in any country other than the Republic of Poland?  info_outline
* field is required
Please indicate the authority conducting the proceedings, the reason for the proceedings, the content of the judgment, to whom it was passed and if it has been executed 
6. Have you or has any member of your family ever had any criminal proceedings pending in any country other than the Republic of Poland?  info_outline
* field is required
Please indicate the authority conducting the proceedings, the reason for the proceedings, the content of the judgment, to whom it was passed and if it has been executed 
7. Have you or has any member of your family ever been sentenced by court in any country other than the Republic of Poland?  info_outline
* field is required
Please indicate the authority conducting the proceedings, the reason for the proceedings, the content of the judgment, to whom it was passed and if it has been executed 
8. Have you or has any member of your family ever belonged to any organisation or group in your country of origin, for example a political organisation or party or a trade union or have you ever been associated with such an organisation or group?  info_outline
* field is required
If so, please fill in the table below for each person concerned 

1:

Name and surname of that person 
Degree of kinship with the applicant 
Period of activity (from – to) 
Name of the organisation (original name and its abbreviation) 
Type of the organisation 
Function held 

2:

Name and surname of that person 
Degree of kinship with the applicant 
Period of activity (from – to) 
Name of the organisation (original name and its abbreviation) 
Type of the organisation 
Function held 

3:

Name and surname of that person 
Degree of kinship with the applicant 
Period of activity (from – to) 
Name of the organisation (original name and its abbreviation) 
Type of the organisation 
Function held 

4:

Name and surname of that person 
Degree of kinship with the applicant 
Period of activity (from – to) 
Name of the organisation (original name and its abbreviation) 
Type of the organisation 
Function held 

5:

Name and surname of that person 
Degree of kinship with the applicant 
Period of activity (from – to) 
Name of the organisation (original name and its abbreviation) 
Type of the organisation 
Function held 
9. Are you or is any member of your family still active in any organisation or group in your country of origin, for example a political organisation or party or a trade union, or are you or is any member of your family in any other way associated with such an organisation or group?  info_outline
* field is required
Please indicate the person concerned 

PART V

OTHER INFORMATION

1. Have you or has any person on behalf of whom you are acting ever had any criminal proceedings pending in the Republic of Poland?  info_outline
* field is required
Please indicate the authority conducting the proceedings, the reason for the proceedings, the content of the judgment, to whom it was passed and if it has been executed 
2. Have you or has any memeber of your family* ever applied for international protection in the Republic of Poland or in any other country?  info_outline
* field is required
Please indicate, who it was and provide the following information 

1:

Country 
Year 
Type of the decision (positive, negative, no decision) 
Did you or any memeber of your family return to the country of origin after the final decision had been issued? 

2:

Country 
Year 
Type of the decision (positive, negative, no decision) 
Did you or any memeber of your family return to the country of origin after the final decision had been issued? 

3:

Country 
Year 
Type of the decision (positive, negative, no decision) 
Did you or any memeber of your family return to the country of origin after the final decision had been issued? 
3. Does any member of your family*, including relatives**, in case of an unnaccompanied minor, reside on the territory of the Republic of Poland or any other European Union Member State?  info_outline
* field is required
Please provide their data 

1:

Name (names) 
Surname 
Date and place of birth 
Degree of kinship 
Residence address 
Legal title to stay 

2:

Name (names) 
Surname 
Date and place of birth 
Degree of kinship 
Residence address 
Legal title to stay 

3:

Name (names) 
Surname 
Date and place of birth 
Degree of kinship 
Residence address 
Legal title to stay