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MINISTRY OF CULTURE AND TOURISM

OF THE REPUBLIC OF INDONESIA


DIRECTORATE GENERAL OF HISTORY AND ARCHAEOLOGY
Komplek Depdiknas Gedung E Lantai 11 Phone & Facsimile e-mail: amerta@jakarta.wasantara.net.id
Jalan Jenderal Sudirman, Senayan Jakarta 10270 (021) 5725512, 5725061 ext. 6116 Website: www.purbakala.net

Number : ………………………………………………

Enclosed : ………………………………………………

Subject : Transport permit of goods abroad

1. a. Application by : ………………………………………………………………………

b. Passport no. : ………………………………………………………………………

Identity Card no. : ………………………………………………………………………

Valid until : ................................................................................................

c. Visa no. : ................................................................................................

Valid until : ................................................................................................

d. Proffesion : ................................................................................................

e. Permanent address : ………………………………………………………………………

f. Temporary address : ................................................................................................

2. Examined by : ………………………………………………………………………

3. Number of goods : ………………………………………. …………………………….

4. Purpose : ………………………………………………………………………

5. Destination : ………………………………………………………………………

6. This permit is valid for one journey to : ……………………………………………………………………..

7. Applicant must be reported to Directorate of Archaeological Heritage, Jenderal Sudirman Street, E


Building, 11 floor, the Ministry of National Education, Senayan, Jakarta, latest 3 months after
arrival in the destination.

8. Other : ………………………………………………………………………….

Issued by : ……………………………
Date : ……………………………

Director of Archaeological Heritage,

( ………………………………………)
Copies to :
1. Director General of History and Archaeology
2. Head of Inspection Office Tipe A1, Directorate General of Customs,
Ministry of Finance of the Republic of Indonesia;
3. Director of Export, Ministry of Industry of the Republic of Indonesia
APPLICATION

Name : …………………………………………………………………….
Nationality : …………………………………………………………………….
Profession : …………………………………………………………………….
Address : …………………………………………………………………….
Identity Card
No : ……………………………..
Issued by : …………………………………………………………………….
Passport
No : ……………………………..
Issued by : …………………………………………………………………….
Visum
No : ……………………………..
Issued by : …………………………………………………………………….
Address : …………………………………………………………………….
In Indonesia : …………………………………………………………………….
Abroad : …………………………………………………………………….
Applies for a permit to transport the following commodities:
Item : …………………………………………………………………….
Number : …………………………………………………………………….
Destination : …………………………………………………………………….
Purpose : …………………………………………………………………….
Enclosed herewith are colour photographs of commodities : ……………...............
Hereby, I state that I will respect the stipulation conditioned to the issuance of the
approval.
Jakarta, ……………………………
Applicant,

(…………………………………….)
STATEMENT

Name : …………………………………………………………………….
Profession : …………………………………………………………………….
Address : …………………………………………………………………….
Purpose : …………………………………………………………………….
Herewith confirms the truth that the following goods:
Item : …………………………………………………………………….
Material : …………………………………………………………………….
Number : …………………………………………………………………….
Characteristic : …………………………………………………………………….
…………………………………………………………………….
Are his personal belongings obtained by
Inheritance : …………………………………………………………………….
Present / Gift : …………………………………………………………………….
Procurement at : …………………………………………………………………….

This statement is made truthfully by

Jakarta, ……………………………

(…………………………………….)
Attachment

TYPOLOGICAL LIST OF TRANSPORT GOODS INTER-REGIONAL/ABROAD

Date : ………………….....

No : …………………….

On behalf : …………………….

No Object/item Number Material Colour Type Measure Period Documentation Condition