Visa Application Form - Consulate General Of The Republic Of Indonesia Page 2

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III. P
ASSPORT INFORMATION
Passport/Travel Document Number:
Place of Issue:
Date of Issue:
Date of Expired:
IV. SPONSOSHIP IN INDONESIA
Type of Sponsor:
Individual
Government
International Institution
Company
NGO
Others
Name of Sponsor:
Address:
City:
State:
Zip:
Phone Number:
-
-
V. MISCELLANEOUS
Have You ever been to Indonesia before?
Yes
No
Are You in possession of any other countries travel documents?
Yes
No
Do You have previous visa to enter Indonesia?
Yes
No
Have Your visa application been denied before?
Yes
No
Have You ever been forced to leave Indonesia?
Yes
No
Have You ever been committed a crime or any offence?
Yes
No
Return/Through Ticket:
Place of Issue:
Date of Issue:
-
-
(DD-MM-YYYY)
Date of Expired:
-
-
(DD-MM-YYYY)
I hereby declare that the statements given above are true and I understand that even if granted a visa,
admission at the airport remains the discretion of the Immigration authorities in Indonesia.
Applicant’s Signature
_____________________ , _____ - _____ - __________ (Place, DD-MM-YYYY)

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