CONSULATE GENERAL OF THE REPUBLIC OF INDONESIA

DUBAI - U.A.E
Al Mina Road Street No.2 A Villa No.1 Community 322 Bur Dubai U.A..E
Tel.+97143985666 Fax. +97143980804 www.indonesianconsulate.ae
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I GENERAL

Length of Stay in Indonesia Day(s) Month(s) Year(s)

Date of Entry

Port of Entry into Indonesia

Transit (go to "A") Single Visit (go to "B")
Type of Visa
Multiple Visit (go to "B") Limited Stay (go to "C")
A For Transit Purpose

Country of Destination

Port of Departure

Flight No / Vessel Name

B For Visit Purpose
Tourism Convention Family Visit Sports
Type of Visa
Study Arts Commercial Others

Place of Visit

Flight No / Vessel Name

C For Limited Stay Purpose

Purpose of Limited Stay

Address in Indonesia

City Province

Phone Number Cell Ph.

II PERSONAL DATA

First Name

Middle Name

Last Name
Sex / Marital Status Male Female Married Unmarried

Place & Date of Birth

Nationality

Address

City / Post Code Country

Phone /Cell Phone Number E-mail

 Occupation / Position Professional Government Sales Student Housewife Others

Name of Company

Address

City Country

Phone Number Cell Ph.

III PASSPORT INFORMATION

Passport/Travel Document No

Place of Issue (city)

Date of Issue Expiry

Type of Passport Ordinary Diplomatic Service
IV SPONSORSHIP IN INDONESIA
Type of Sponsor Individual Government Reg/Intl. Organization
Company NGO Others

Name of Company

Address

City Province

Phone / Cell Phone Number E-mail

V MISCELLANEOUS
Have you ever been to Indonesia before ? Yes No
Do you have a previous visa to enter Indonesia ? Yes No
Has your Visa application been rejected before ? Yes No
Have you ever been forced to leave Indonesia before ? Yes No
Have you ever been convicted of a crime or an offence ? Yes No

Flight Name & No.

I hereby declare that the statements given above are true and I understand that if granted a visa,
admission at the airport remains at the discretion of the Immigration authorities in Indonesia

Date Today
Signature * To be completed with 2 (two) photograph attached.
* Passport must be valid at least 6 (six) months

FOR OFFICIAL USE ONLY

Telah diberikan Visa atas kuasa sendiri :

Macam Visa : ......................................................................................

Nomor Visa : ......................................................................................
Lama diijinkan tinggal : ......................................................................................
Dubai, ......................................................................

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