PART B

Name of State Logo of State (Name of Office) (1) REFUSAL OF ENTRY AT THE BORDER On at (time) at the border crossing point We, the undersigned, have before us: Surname First name Date of birth Place of birth Sex Nationality Resident in Type of identity document number Issued in on Visa number type issued by valid from until For a period of days on the following grounds: Coming from by means of (indicate means of transport used, e.g. flight number), he/she is hereby informed that he/she is refused entry into the country pursuant to (indicate references to the national law in force), for the following reasons: (A) has no valid travel document(s) (B) has a false/counterfeit/forged travel document (C) has no valid visa or residence permit (D) has a false/counterfeit/forged visa or residence permit (E) has no appropriate documentation justifying the purpose and conditions of stay. The following document(s) could not be provided: (F) has already stayed for three months during a six-month period on the territory of the Member States of the European Union (G) does not have sufficient means of subsistence in relation to the period and form of stay, or the means to return to the country of origin or transit (H) is a person for whom an alert has been issued for the purposes of refusing entry in the SIS in the national register (I) is considered to be a threat to public policy, internal security, public health or the international relations of one or more of the Member States of the European Union (each State must indicate the references to national law relating to such cases of refusal of entry). Comments The person concerned may appeal against the decision to refuse entry as provided for in national law. The person concerned receives a copy of this document (each State must indicate the references to the national law and procedure relating to the right of appeal). Person concerned Officer responsible for checks (1) No logo is required for Norway and Iceland.

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Source: EUR-Lex (Cellar) · retrieved 2026-11-14 · Text as adopted (Official Journal); later amendments are not incorporated in this text.