EMBASSY REPUBLIC OF INDONESIA IN KUALA LUMPUR VISA APPLICATION FORM FOR VISIT - SINGLE / SEVERAL JOURNEY (S) (BUSINESS , TOURISM , SOCIAL CULTURAL / EDUCATIONAL) re Full name of appli Female / Male Place and date of Birth 2. Nationality... Passport Number/ Travel Documents: Place and date of issuance . Valid unt 3. Entry Permit/ Visa to another Country Number Place and date of issu Expiration date:.. areas 4, Name (s) of family members included in applicants passport who are appl 1g for visa. Full Name Family Sex Place and date (Chinese applicant, included code number)| Relationship of birth 2 3. 4 5 : 3S. Permanent Address Phone No : 6. Oceupation/position ‘Name of firm of employment -Addtess of frm and telephone num [Name of reference in Indonesia: Address of reference it : us Do youhave letter of invitation: Purpose of visit to Indonesia : Please circle one according to the nature of your visit BUSINESS VISIT SOCIAL/ CULTURAL VISIT O1, Industrial 10. Social 02. Commercial 11, Health and Medical 03, Agricultural 12, Educational 04, Mining 13, Arts 05. ‘Transport and Telecommunications 14, Sports 06, Public Works and Public Utilities 15, Family Visit 07, Religious 16, Tourism 08. Press and Public Communications 17. Study 09. Promotion Visit 18, Others Length of intended stay in IndonesicPrevious visa for Indonesia to the applicant : ‘Type: ‘Number: Place and date of issue : lace and date previous entry into Indonesia 8. Has your application for Indonesian visa ever been denied :. Have you ever been ordered to leave Indonesi Have you ever been arrested or convicted ora criminal act 9. Other informa ‘4. Are you in possession of other country's legal and valid Immigration document b, Number of Return / Through Ticket Aitline Company £m Place and date of issve =. Expiration date : which will be useful in considering this s application : hereby declare that : 1. The statements given above are true and correct. 2. Irealize that even though I possess a valid visa to Indonesia, permission for entry remains at the discretion ofthe Immigration authorities in Indonesia am also aware: 1, ‘That during my visit to Indonesia I have refrain from: beeing engaged in any occupation or institution paid or unpaid. bover staying 2, ‘That ifI fail (o comply with the above mentioned requirements, I am liable to prosecution and expulsion. date Completed at : Signature of applicant (Same as in passport) Full name printed : (fo be completed in duplicate with 2 photographs attached) FOR OFFICIAL USE ONLY SP.No.: 1, Telah diberikan Visa atas kuasa senciri Nomor Visa. : Lamanya diizinkan tinggal di Indonesia See ‘Tanggal Pemberian Visa :. Sresses : 2. Diajukan kepada Direktur Jenderal Imigrasi untuk mendapatkan keputusannya,