KEDUTAAN BESAR REPUBLIK INDONESIA ee SINGAPURA FORMULIR SURAT PERJALANAN REPUBLIK INDONESIA UNTUK WARGA NEGARA INDONESIA PERWATIAN 4. tt ecm dengan MURUE CETAX dan THNTA Mra. Foret astra ene See ee nomor pan Co eeeeest aaa nema anaialion Be ade Ce ee atte area varia Teuton els\dangen sanx pevsrorn ingot eokoion By Latsingelsstinan taaticeasiuan sett ia Yang neninstan paaramn i Cot mematradk on ae fal : 2 6 fam pengisian fo ng jolas, hubungi petugas pelaysnan keimigrasian ern cenaar eta ienpoat beemigiae: wusapeoasiey cinyeakan dengan dua angha, Conton 26 Janar2000.[2[6]0[1[0]@ : FaREOHONAN Tar pesmenowan oan 4 Papo 4 a spe @. PENGOANTIAN* S| fate bert 2. Halaman penuh 3 lang Ruma Cao o. remuean® im _& Ainittanpse age 2 Lamia TmanLeNoe evs Ke a CLELErTrTrTrrrrrrrrirrrrr rr ttt) maa "Ince exDAN TITEPIrrrrrrerrrrrrr ttt tt rr tect Tem LRT TralgehC ARR a anor adeno Ta SET RIN a Ta Shenae CoaaTaD eV | [rca can ARTO PERERA CLLETTEET TT TT Err ttt LTTE TT TTT rT) HERR EEE rete EEE EERE EE a Tea fs a Fea (TELE Crrrrrrrrrrirrri rit try ttt) — BEE oOOCCCCEEE Eee et ebarlonlechman CLIT ETT TTTrroiirirrttyrirtttTrttTr) Falter saison wae | imran (eldeideb eee ee alent Tralee 1 SCRE OOOO CECE eee eee ee eee tt Tf} Frit CEE EL jrees ep [| LTT TI i LTT tf ae a salatertecatan COSC eer rr en ome TANGGALLAMIR CLELLCLErrrrrrrrirtrtyTr ttrePEKERJAAN* 1. PEJABAT NEGARA 2. PEGAWAI NEGERI SIPIL 3. TNI/ POLI 4, PEGAWAI SWASIA 5 LAINNYA, STATUS SIPIL* 1. KAWIN 2. TIDAK KAWIN 3. CERAI MATI 4. CERAI HIOUP ‘elurun Keterangan dan data yang saya nyatakan dalam Tormullr ni adalah sah dan sesval dengan Keadaan yang sebenarnya, dan _pabliadikemudian har ternyata pernyataan ini tidak benar, saya bersedia dituntut sesuai Ketentuan peraturan perundangan yang berlaku ‘Tanda tangan yang diberi kuasa, Tanda tangan pemohon, Nama_[ [TTT Paspor diterima pada tanggal Tanda tangan penevima, Petugas yang menyerahkan, Nama [1 ‘CATATAN PETUGAS LOKET ‘CATATAN PETUGAS WAWANCARA Tampienperyerstan Fo]copy benrry caro Copy EMPLOYER IDENTITY CARD PosporlSPLP Lama Surat Keterangan lang dari Kepotsian Surat RekomendasicnAtasan/Sponsor ‘Surat Kuasa/Kartu Tanda —" Pengenal Pengurusan Keimigrasian Parat Pertugas Paraf Pejim, Nama Lama CATATAN PEGAWAI TATA USAHA LTT Tt LI ‘Alamat Tempat Tinggal Lama pr (omer Paspor! SPLP Lama Berlaku sid ‘Tempat Dikelvarkan Cl [CTT TTT I Nomor Register [ a Nomor Paspor SPLP Baru Barlaki sd fom pai Dkelvarkan O [TTT I Nomot Register Nomor Surat Pergeljdan Kekanwil Kementerian Kumham “Tanggal, a 2 ‘CATATAN PEJABAT IMIGRAS! NiKIN T Parat Pejim, Tanggal Lengkap [7] Tidak Kelengkapan Persyaratan Tanggal Parat Pejim, LTT Tereantum [| Tidak [| ada [] Tek Parat Pejim, Daftar Cokal kel Tanggal Persetujuan Setuju [_] Tidak KAKANIM, TanggalEMBASSY OF THE REPUBLIC OF INDONESIA. SINGAPORE VISA APPLICATION FORM File Number ee ATTENTION! Please fillin all headings using CAPITAL LETTERS. Your application shall not be processed in case of error omission. Notes: * Tick (x) where appropriate | deciare that all data given in this form is complete and true. | am aware that any false statements will lead to my application being rejected or to the annulment of visa already granted and may also render me lable to prosecution under Indonesian Law. | understand that possession of a visa does not entitle its bearer to enter Indonesia. | wll not seek compensation if| am refused to enter Indonesia. . Full Name Of Applicant Fa (same as in passport) see: OM OF Place and Date of Birth 008 Country of Origin —_Nv—-™>-—.__ Photo Emergency contact of origin :—~=S*~*~“*é“‘CS*S*S*S*SCSCSCSCSSSSSSS Passport Size Marital Status Osingie CMaried CJDivorce CJ Widowed 2. Nationality : Passport/ Travel Doc Number: Place of issue For official use Only: Ta! Date of issue Valid Until s oy oT 3, Occupation - penser: Name of Firm in Singapore Persetujuan: ‘Address of Firm Ditienim: = OY OT 4, Address in Singapore : ‘Masa Berlaku Paspor: (for Social & Tourist Visa Only) but oy oF Contact number and email: _ 5. Number of Entries?* DiSingte Entry C1 Mttipie Entry eka) © OY OT Length of intended stay :_Days:_Months:_Years Biaya Visa: OY OT Type of Visa?* Visit Visa CTourism [Business Visit [] Family/Social Visit Kelengkapan syarat: Study — 11 Convention others: Lengkap: =OY OT Temporary stay Visa OStudy = Working (1) Join Family ) CotherPiease Specify) Petugas Counter 6. Where will you be staying in indonesia?* : ‘Teleticieelican ies: CJ Relative's Place Dhote! Type . O Friend's Place ©) Others (Please Specify) ys — Indeks Visa 7. Telex No. ° Name of Reference a Nomor Viea Address of Reference Lamanya Tinggal: 8, Have you ever entered Indonesia using different passport or name?* (Dyes CINo Have your application for indonesian Visa ever been denied?" (Yes [No Have you ever been prohibited from entering Indonesia?” Dyes E]No Disetujui/ Ditolak Have you ever been deported from any country including Indonesia?* Dyes )No Have you ever been arrested or convicted of any criminal act?* Dyes E)No any of the answer is “YES”, please furnish details below: Pejabat imigrasi Signature of Applicant Date k —