diplomatic official form
DESCRIPTION
Application formTRANSCRIPT
EMBASSY OF THE REPUBLIC OF INDONESIAIN KUALA LUIIIPUR
Date : l-Tl - m - [I-[*T_ltoDMM-YYYr)Applicalion Number :
Authorization Number :
I. GENERAL
Length ofStay in Indonesia * :
Type ofMsa t
Category of Msit'
Purpose of Visit *
Destination Address in Indonesia
City
Province
Phone Number
Point of entry into lndonesia "
FlighWessel Name and Number
Date of entry
Date of Departure *
Previous Couniry Visited
PERSONAL DATA
First Name *
Middle Name *
Family / Surname *
Sex *
Marital Status.
Place of Birth "
Date of Bifih *
Nationality *
Address *
City
ProvincelState
Phone Number
Occupation t
Current Position *
Name of InstMion *
Address
City
ProvincelState
Phone Number
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llRosting flconferenceM/orkingvisit flTourism
flTransit flottters
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III, PASSPORT INFORMATION
Type of Passport t
Passpori/Travel DocumentNumber* :
Place of lssue/ lssued by * t
Date of lssue " :
Date of Expiry * :
CategoryofPassport :
Fill if it is cateooN of Passport Family :No. Relative(s): Sex : Date of Birth (DDl,Sr-YfYD Name :
n;H;;t-J
n m-m'rrrl]?elative(s) : 1=Husband, 2=Wife, 3=Child)*(Sex F=Female, M=Male)
U, SPONSORSHIP INFORMATION
Sponsorship in lndonesia
Name of lndMdual
Current Posilion
Name lnstitution
Address
City
Phone Number
v. MISCELLANEOUS
Have you ever b€en to Indonesia before?.
]f 'Yes' Date of Visit
Purpose of Visit
Are you in possession of any other countries' travel documents?
Do you have previous visa to enter Indonesia?
Have your visa application been denied before ?
Have you ever been forced to leave Indonesia?
Have you ever been commited a crime or any offence?
Do you have health problem condition?
' Iv"" [*o: flves f_lruo, flv"s f-lruo: f]v"" [-lno, f]v"" Ito, f-]y"" Iruo
lf 'Yes' please give detail
Haveyoubeenpreviouslyposfiedabroad? : I lYes I lNoff'Yes' please give delails 2 previous posting : 1
' | - - -__*_l, fTl ' fT--l -[T-fT]@D'MM-YYYY)
DateorExpiry' ' [Tl-f-n-fT-IT-I(DD-MM-YYYY)l, hereby, declare that the statements given above are true and I understand that even if granted a visa,prerequiles checked administration at the airpoft remains the discretion of the lmmigration authorities in Indonesia
: [otptomati" f] service [lurup l*-]om"o
rl--l - fT-'l - [T-fTI(DDMM.YYYY)t-l--l - fT-l fTI-II(DD-MM-YYYY)[eersonat f_-.lFami[
: [ltndividual f_lGovernment
f--lr,rcol-ltnst'tution
[l International Instr'tution
f--lottters
: IYes f_lNo
' [T_l - [T-l - f*T-[T*l(DuMmYwv),
Place of lssue
Date of lssue "
Applicanfs Signature
1. To be completed with Original Paspor & 12. Copy Paspor and Msa3. Diplomatic/Offi cial Note4. Passport must be valid at leasl six months before exoired
Collected Docs by,No : Tanggal:
diberikan: Single/MuhipleardKawat KEMLU I lMelapor ke KEMLU | |
oleh, Dipersiapkan oleh, lsign & Name :Date:Hp: