Invoice No :

CONSULATE GENERAL OF THE REPUBLIC OF INDONESIA IN

JEDDAH

Reg.No

Address: Al Muallifin Street Rehab Dist/5 P.O.Box.10,Jeddah 21411 Telp. : 671-1271 Fax. : 673-0205

Date

: :

(DD-MM-YYYY) Day(s) Transit Muliple Visit Month(s) Single Visit Limited Stay Year(s)

I. GENERAL Length of Stay in Indonesia

Foto

For Transit Purpose Country of Destination Port of Departure Fligth/Vessel Name Visit Purpose Purpose of Visit

: : : : : : : Tourism Study Convention Arts Family Visit Commercial Sports Others

Country of Destination Place of Visit Flight/Vessel Name For Limited Stay Purpose Purpose of Visit Address in Indonesia City Province Phone Number Port of entry into Indonesia Date of entry II. PERSONAL DATA First Name Middle Name Family / Surname Sex Maritial Status Place of Birth Date of Birth Nationality Address City Province/State Phone Number Occupation/Position

: : : Work : : : : : : (DD-MM-YYYY) Joint Family Social Others

: : : : : : : : : : : : : Professional Student Govermment House wife Sales Others (DD-MM-YYYY) Male Married Female Single

Name of Company Address

: :

City Province/State Phone Number

: : :

III. PASSPORT INFORMATION Passport/Travel Document Number Place of Issue Date of Issue Date of Expiraion Type of Passport * * No. Fill if type Passport Family Relative(s) Sex: Date of Birth(DD-MM-YYYY) *(Relable(s) : 1=Husband, 2=Wife, 3=Child) *(Sex : F=Female, M=Male) IV. SPONSORSHIP IN INDONESIA Type of Sponsor : Individual Company Name Company Address City Province/State Phone Number V. MISCELLANEOUS Have you ever been to Indonesia before ? Are you in possession of any other countries travel documents ? Do you have previuos 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 Expiration : : : : (DD-MM-YYYY) (DD-MM-YYYY) : : : : : : Yes Yes Yes Yes Yes Yes No No No No No No : : : : : Government NGO International Intitution Others : : : : : Personal Family (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 remains the discretion of the immigration authorities in Indonesia. Applicant's signature

* *

(DD-MM-YYYY)

To be complete in duplicate with two photographs attached. Passport must be valid at least six months.