Visa Application Form - Embassy Of The Republic Of Indonesia Page 2
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Purpose of Travel
Tourism
Family Visit
Study
Internship
Press & Media
Film Making
Arts
Sports
Workshop
Seminar
Conference
Business/Commercial Industry
Mining
Agriculture
Official Visit/Meeting
Diplomatic Posting
Others:
5
Length of stay and Flight / Cruise Ship information to and from Indonesia
Length of Stay (days)
Date of Entry
City and Port of Entry
City and Port of Exit
Date of Exit
Flight / Cruise Ship Number
Flight / Cruise Ship Number
6
Hotel Name and Address in Indonesia (first arrival)
Hotel Name:
Hotel Address :
City & Province:
Phone Number:
7
Indonesian Sponsor (not applicable to Tourism)
Name of Sponsor
Sponsor’s Title/Position
Work Phone: Area code / Number
Name of Company / Institute
Fax Number : Area code / Number
City / Province
Postal Code
Mobile (if any) : Area code / Number
8. Are you in Possession of other Country’s Valid Passport
If Yes, Specify the Country:
Yes No
9
Does any of the following apply to you
Yes
No
Please Specify:
a
Have you ever travelled to Indonesia
Has your visa application for Indonesia ever been
b
denied
c
Have you ever been ordered to leave Indonesia
Have you ever been arrested or convicted of a
d
criminal act?
Applicant’s Signature and Date
1.
I hereby declare that the statement given above is true and correct to the best
of my knowledge.
2.
I understand that possession of a Visa does not automatically entitle the
bearer to enter Indonesia upon arrival if he or she is found inadmissible.
3.
I understand that any false or misleading statement may result in permanent
refusal of a visa or denial of entry into Indonesia.
4.
I am also aware that failing to comply with the above requirements, I will be
liable to prosecution or expulsion.
Date :
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