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Formulir Visa

This document is a visa application form for entry into Indonesia. It requests information about the applicant's passport, personal details, purpose and duration of visit, sponsorship or contacts in Indonesia, and previous travel history. The applicant must provide their name, birthdate, nationality, occupation, passport information, destination and length of stay. For work or family visits, the applicant discloses their address and contact in Indonesia. By signing, the applicant declares the information is true and that entry is subject to approval by Indonesian immigration authorities.

Uploaded by

Shoaib Aziz Meer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
449 views2 pages

Formulir Visa

This document is a visa application form for entry into Indonesia. It requests information about the applicant's passport, personal details, purpose and duration of visit, sponsorship or contacts in Indonesia, and previous travel history. The applicant must provide their name, birthdate, nationality, occupation, passport information, destination and length of stay. For work or family visits, the applicant discloses their address and contact in Indonesia. By signing, the applicant declares the information is true and that entry is subject to approval by Indonesian immigration authorities.

Uploaded by

Shoaib Aziz Meer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

No.

EMBASSY OF THE REPUBLIC OF INDONESIA


38 Grosvenor Square, London W1K 2HW
Consular Section Entrance : 38a Adams Row
(Rear of the Embassys Building)
Tel
: 020 - 7499 7661 * Fax : 020 - 7491 4993
====== ====================================================================================
Affix

GENERAL

Photograph

Port of Entry into Indonesia : .


Date of Entry
: _ _ - _ _ - _ _ _ _ (DD-MM-YYYY)
Length of stay in Indonesia :
Type of Visa

For Transit Purposes

Day(s)

Month(s)

4X6

Year(s)

Transit

Single Visit

Multiple Visit

Limited Stay

(Multiple & Limited visas Require Immigrations Approval/Authorization)

Country of Destination
: ..
Port of Departure
: ..
Flight / Vessel Name & No. : ..
For Visit Purposes
Type of Visit

Tourism

Convention

Family/Social

Study

Arts

Commercial

Sports

:
Others
(please Specify)

Country of Destination
: ..
Place of Visit
: ..
Flight / Vessel Name & No. : ..
For Limited Stay Purpose
Purpose of stay

Work

Join Family

Social

Others

Address in Indonesia
City
Province
Phone Number

: .
: .
: .
:___-___-________

(Please Specify)

II. PERSONAL DATA


First Name
Middle Name
Family / Surname

: .
: .
: .

Sex

Marital Status
Place of Birth
Date of Birth
Nationality
Address in UK / Ireland
City
County / Postcode

:
:
:
:
:
:
:

Male

Female

Married
Single
..
_ _ - _ _ - _ _ _ _ (DD-MM-YYYY)
.....
..
..
..
1

Phone Number

: ___-___-________

Occupation / Position
Name of Company
Address
City
County / Postcode
Phone Number

:
:
:
:
:
:

Professional

Government

Mobile #: _ _ _ _ _- _ _ _ _ _ _
Sales

Student

Housewife

Other

.
.
.
.
_ _ _ - _ _ _ - _ _ _ _ _ _ _ _ Fax #: _ _ _ _ _- _ _ _ _ _ _

III. PASSPORT INFORMATION


Passport / Travel Document Number :
Place of Issue
:
Date of Issue
: _ _ - _ _ - _ _ _ _ (DD-MM-YYYY)
Date of Expire
: _ _ - _ _ - _ _ _ _ (DD-MM-YYYY)
Type of Passport
:
Personal
Family
Family details for holder of Family Passport :
No.
Relations
Sex* Date of Birth (DD-MM-YYYY)
NAME
.
.
..
.
.
..
.
.
..
* F = Female M = Male
IV. SPONSORSHIP IN INDONESIA
Type of Sponsor
Sponsors Name
Address
City
Province / State
Phone Number

:
:
:
:
:
:

Individual

Government

International Institution

Company

NGO

Others

..
..
..
..
___-___-________

V. MISCELLANEOUS (Please circle the answer)


Have you ever been to Indonesia before?
:
Are you in possession of 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 committed a crime or any offence?
:
Return / Through Ticket / Airline Company
Place of Issue
Date of Issue
Date of Expire

:
:
:
:

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

.
.
_ _ - _ _ - _ _ _ _ (DD-MM-YYYY)
_ _ - _ _ - _ _ _ _ (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/seaport remains the discretion of the Immigration Authorities
in Indonesia.
Applicants Signature (for minors, signature of custodian/guardian)
Place and Date (DD-MM-YYYY) :
., _ _ - _ _ - _ _ _ _
* Passport must be valid at least six months from date of entry !
2

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