perwakilan republik indonesia di wellington perdim 22 …
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PERWAKILAN REPUBLIK INDONESIA DI WELLINGTON PERDIM 22 THE EMBASSY OF THE REPUBLIC OF INDONESIA IN WELLINGTON
70 GLEN ROAD, KELBURN, WELLINGTON 6012 NO: Ph. (04) 47586 97/98/99 Fax. (04) 4759374 Email: [email protected]
FORMULIR VISA – VISA APPLICATION FORM
PERHATIAN - ATTENTION
1. Isi Formulir dengan HURUF CETAK dan TINTA HITAM.
Fill this form using CAPITAL LETTERS and BLACK INK.
2. Tanda asterisk (*) berarti diisi sesuai nomor pilihan.
Fill the box with asterisk (*) with the most suitable option.
3. Tanda asterisk (**) berarti diisi bagi pemohon VITAS.
Fill the box with asterisk (**) if you are applying for Limited Stay Visa only.
4. Cara pengisian tanggal adalah dengan urutan tanggal-bulan-tahun, masing-masing dinyatakan dengan dua angka. (dd/mm/yy).
Fill the date boxes with (dd/mm/yy) format.
PERMOHONAN – Application* TGLPERMOHONAN
1. VISA KUNJUNGAN SATU KALI PERJALANAN – Single Visit Visa Date of Application
2. VISA KUNJUNGAN BEBERAPA KALI PERJALANAN – Multiple Visit Visa
3. VISA TINGGAL TERBATAS – Limited Stay Visa
NAMA LENGKAP – Full Name JENIS KELAMIN – Sex* 1. L – Male 2. P - Female
TEMPAT LAHIR – Place of Birth TGL LAHIR – Date of Birth
NO. PASPOR – Passport/Travel Document No. TGL DIKELUARKAN – Date of Issue
TEMPAT DIKELUARKAN – Place of Issue (Authorization) BERLAKU S/D – Expiry Date
KEWARGANEGARAAN – Nationality ALAMAT EMAIL – Email Address
PEKERJAAN DI INDONESIA - Occupation in Indonesia** TELEPON – NZ Phone Number
PEKERJAAN DI SELANDIA BARU – Occupation in NZ STATUS PERKAWINAN – Marital Status*
1. Married |2. Single |3. Other
ALAMAT TEMPAT TINGGAL DI INDONESIA – Address of Residence in Indonesia
TELEPON – Ph. Number
ALAMAT TEMPAT TINGGAL DI SELBAR – Address of Residence in New Zealand
TELEPON – Ph. Number
ALASAN PERMOHONAN VISA – Reason for Applying Visa/Visit purpose (please elaborate)
PENERBANGAN MASUK – Flight Number INTO Indonesia TANGGAL MASUK – Date of Arrival
PENERBANGAN KELUAR – Flight Number OUT OF Indonesia TANGGAL KELUAR – Date of Departure
LAMA TINGGAL – Length of Stay
PERWAKILAN REPUBLIK INDONESIA DI WELLINGTON PERDIM 22 THE EMBASSY OF THE REPUBLIC OF INDONESIA IN WELLINGTON
70 GLEN ROAD, KELBURN, WELLINGTON 6012 NO: Ph. (04) 47586 97/98/99 Fax. (04) 4759374 Email: [email protected]
NAMA SPONSOR – Name of Reference (If applicable)
ALAMAT SPONSOR – Address of Reference (If Applicable)
SECURITY QUESTIONS (Tick where applicable)
• Have you ever been to Indonesia? __Yes __No
• Are you in possession of any other country passport other than your nationality? __Yes __No Please state your dual nationality (if applicable): _________________________
• Have you previously been granted a visa to enter Indonesia? __Yes __No
• Have your Indonesian visa application ever been denied? __Yes __No
• Have you ever been deported from Indonesia? __Yes __No
• Have you ever committed a crime or been arrested? __Yes __No I DECLARED that all the statement and data in this form is legal and based on real situation. Should in the future be found that this statement is not true, I am willing to be sued according to the prevailing regulation (Republic of Indonesia Immigration Act No.6 Year 2011). TANDA TANGAN PEMOHON
Signature of Applicant **** For children less than 18 years old, please enclose:
1. Copy of Birth Certificate 2. Copy of Marriage Certificate of the parents 3. Consent form (perdim 22a)
__________________________________
CATATAN PETUGAS – For Official Use Only
Lampiran Persyaratan: Paraf Petugas, Surat Sponsor / Letter of Sponsorship
Paspor/Dokumen Perjalanan / Passport
Kopi Surat Persetujuan Ditjenim / Approval Letter from Immigration _____________________
Pasfoto Terbaru Latar Belakang Putih / 1 Photograph
Tiket Pesawat PP/ Flight Details
Bukti Finansial / Proof of Finance
NOMOR VISA INDEKS VISA
TGL DIKELUARKAN BERLAKU S/D
TEMPAT DIKELUARKAN
NO. PERSETUJUAN DITJENIM TANGGAL
CATATAN PEJABAT PERWAKILAN RI
NIORA Kelengkapan persyaratan Lengkap Tidak
Tanggal Tanggal
Daftar Cekal Ada Tidak Persetujuan Setuju Tidak
Tanggal Tanggal Kepala Perwakilan RI,
______________
Please Attach
a recent passport size
colour photograph