ANNEX ISupplementary provisions
ANNEX I FORM FOR NOTIFYING REFUSAL OF AN ETIAS TRAVEL AUTHORISATION in accordance with Regulation (EU) 2018/1240 Application number: _______________ Dear ________________, [In case of a minor, the person exercising permanent or temporary parental authority or legal guardianship is to be added: Dear ________________,] The [name of ETIAS National Unit] in [address of ETIAS National Unit] has examined [name of applicant [optional: additional personal data of applicant]]’s application for [travel authorisation]/[travel authorisation with limited territorial validity]. The application has been refused on the following ground(s): ☐ the travel document used has been reported as lost, stolen, misappropriated or invalidated in SIS in … (indication of Member State) (Article 37(1)(a)) ( * ) ☐ security risk (Article 37(1)(b)) ( * ) ☐ illegal immigration risk (Article 37(1)(c)) ( * ) ☐ high epidemic risk (Article 37(1)(d)) ( * ) ☐ alert for refusal of entry and stay entered in SIS (Article 37(1)(e)) ( * ) by … (indication of Member State) ☐ failure to reply within the 10 day deadline to a request by the ETIAS National Unit for additional information or documentation (Article 37(1)(f)) ( * ) ☐ failure to attend an interview as requested by the ETIAS National Unit (Article 37(1)(g)) ( * ) ☐ reasonable and serious doubts concerning the data/statements and/or supporting documents provided for the application (Article 37(2)) ( * ) (please specify): ☐ reliability of the data submitted ☐ reliability of the statements made ☐ authenticity of the supporting documents submitted ☐ veracity of the content of the supporting documents submitted ☐ the following Member State(s) provided a negative opinion on your application: … [indication of the Member State(s)] [For application for a travel authorisation with limited territorial validity: ☐ the following ground(s) for application for a travel authorisation with limited territorial validity are not fulfilled: ☐ humanitarian grounds in accordance with the national law of the Member State to which the third-country national concerned intends to travel ☐ reasons of national interest ☐ international obligations] Statement of relevant facts and additional reasoning underlying the decision: Right of appeal You have the right to appeal against the decision of [name of the Member State of the ETIAS National Unit responsible]. [Link providing information regarding the applicable national law regarding the lodging of appeals against the decision taken by the ETIAS National Unit responsible as referred to in Art.16(7) of Regulation (EU) 2018/1240.] [Where applicable: You have the right to appeal against the negative opinion on your application by [name of the Member State of the ETIAS National Unit(s) which issued a negative opinion].] [Where applicable: Link providing information regarding the applicable national law regarding the lodging of appeals against the decision taken by the ETIAS National Unit issuing a negative opinion]. Your rights with regard to the processing of personal data You have the rights to access, rectify, erase and restrict the processing of personal data stored in ETIAS in accordance with Articles 17 to 20 of Regulation (EU) 2018/1725 and Articles 15 to 18 of Regulation (EU) 2016/679. In case you wish to make use of these rights, please find below the relevant contacts: European Border and Coast Guard Agency Data protection officer [email address] European Data Protection Supervisor [contact details] National supervisory authority of the Member State responsible for your application [Member State-specific information] [Date and place of decision] [Name and signature of decision-maker] ( * ) of Regulation (EU) 2018/1240