APPLICATION FORM TO OBTAIN A SPECIAL RESIDENCE PERMIT ISSUED BY THE PROTOCOL DIRECTORATE(1)

Fsingle widowed legal cohabitant since:

Relationship:

Datum van d

childadopted childchild under custody

indiensttreding :

date :

(signature ) (Signature of the applicant)

Photo to be adhered with glue(2)

Office holder :

title: spouse legal cohabitant

consular officer - rank(4): consular employee honorary consul VNC-London Agreement

diplomat - rank(4)(5):member of the administrative & technical staff member of the service staff private servant

box:no:

no

Street: Postal code: municipality: Previous address prior to arrival: Earlier residence(s) in Belgium:

If yes, provide address and reason:

Professional activity exercised in Belgium and/or abroad:

If yes, please specify:

no

(name of Head of Mission/organisation or the authorized officer)

Diplomatic mission/Organisation:

Name(3):First name(3):Place and country of birth:

Civil Status: Gender: M married since: divorced since:

Staff category/family member:

seconded national expert official on official mission official NGIOmilitary trainee

e-mail:date of arrival in Belgium:

yes

I have read the provisions on the back of this page regarding the protection of privacy and instructions for completing the form;I do not have the Belgian nationality nor do I hold a permanent residence permit.

I hereby declare that:

© diplobel 2019 nr. P1.1/2.2/EN

KONINKRIJK BELGIË

Federale Overheidsdienst Buitenlandse Zaken, Buitenlandse Handel en Ontwikkelingssamenwerking

Nationality:Date of birth:

Seal of the Mission/organisation

Personal data:

Private address in Belgium:

Family member of: name:

New functionReplacementIdentity of the predecessor:

Description of the function(6): administration of secondment(7): Military rank:

Start date:Functional authority(8):

yes

otherhead of mission

-

-

Protection of privacy

By submitting this form, the applicant expressly authorizes the Protocol Directorate of the FPS Foreign Affairs to collect and manage the personal data recorded above for the purpose of producing and issuing a special residence permit and handling of files of diplomatic missions and international organizations and their staff members.

The Protocol Directorate is subject to the Belgian law of 30 July 2018 on the protection of natural persons with regard to the processing of personal data, according the European General Data Protection Regulation (GDPR).

In accordance with the Vienna Convention of 18 April 1961 on Diplomatic Relations, the Vienna Convention of 24 April 1963 on Consular Relations and the Royal Decree of 30 October 1991 regarding the residence documents of certain foreign nationals in Belgium, the Protocol Directorate has a legal commitment to process such personal data.

All personal data registered in this context will be processed in accordance with the law of 30 July 2018 and will be treated and processed in the safest way. The personal data is saved during the necessary period to manage the various processing processes and provide the service. On the basis of our legal obligation, we share personal data with other (governmental) authorities (producer of special residence permits, FPS Finance, IVD, Immigration Service, FPS Home Affairs, municipalities). They are in no way used or disclosed for commercial purposes.

The applicant can gain access to his data through the diplomatic mission or the international organization.

If you have any questions or would like more information about our privacy policy, you can contact the Data Protection Officer (DPO) of the FPS Foreign Affairs at the following address: DPO@diplobel.fed.be.

Instructions for completing the form:

1.Complete this document in its entirety and clearly, preferably electronically, and return the completed form RECTO VERSO to the Protocol Directorate.

2.For easy identification,the photograph must be very similar to the passport photo and the holder of the document

for easy identification and must comply with the requirements set out in Annex VI of Chapter 4 of the "Protocol Guide"

3.As stated in the passport.

4.See No. 2.2.1.2 of the "Protocol Guide" for the usual grades. 5.For the military, specify the military rank at the ad hoc place. 6.Describe the function, eg driver, accountant, security officer, etc

7.The administration of the sending State to which the agent belongs (for example, the Ministry of Foreign Affairs, the Ministry of Defense, the Ministry of Agriculture, etc.).

8.Mandatory field for diplomat and administrative and technical staff member. In this context, diplomatic missions and

consular posts are reminded that each member of the mission or post is expected to work under the authority,

control and diplomatic responsibility of the head of the mission or post. The latter is, either the ambassador of the bilateral mission or the head of the consular post or the permanent representative or head of mission of the

multilateral mission (see No. 2.3 of the Guide to the Protocol). As a result, only in the case where the "Head of Post" option is checked as the functional authority of the staff member concerned, Protocol Directorate may grant a

privileged status corresponding to the categories of staff provided for in the Vienna Conventions of 1961 and 1963, within the conditions described in the Protocol Guide. By choosing the option "other", the concerned agent can only

be granted the status set up by the regulatory framework organizing the function performed outside the mission.

General comment:

Failure to comply with the formalities prescribed, submission of incomplete or unsigned information forms or illegible copies of supporting documentation may significantly delay the registration procedure with the Protocol Directorate,

as well as the issuing of special residence permit. Diplomatic Missions and organisations are therefore asked to ensure that the information and documents requested are submitted in proper and due form.