VISA APPLICATION FORM TO ENTER JAPAN, (Paste photo here) Official use only «45mm xaSmm or2inxain ‘Surname (as shown in passport) NAMA DEPAN SESUAI PASPOR Given and middle names (as shown in passport), NAMA SELANJUTNYA SETELAH NAMA DEPAN Other names (including any other names you are or have been known by) Date of birth TGL LAHIR Place of birth TEMPAT LAHIR, | Daan ay EO EINE can Sex: Male [] Female L] Marital status: Single [] Married ] Widowed [] Divorced [] Nationality or citizenship __ INDONESIA i Former and/or other nationalities or citizenships ID No. issued to you by your government. NO NIK KTP. Passport type: Diplomatic [] Official [] Ordinary [] other [] Passport No. NO PASPOR Place of issue TEMPAT DI KELUARKAN PASPOR Date of issue TGL TERBIT |ssuing authority TEMPAT PEMBUATAN PASPOR (KANTOR IMIGRASI APA) Date of expiry al LORE Purpose of visit to Japan TECHNICAL INTERN TRAINING see Intended length of stay in Japan ONE YEAR Date of arrival in Japan_15 APRIL 2022 Port of entry into Japan_KANSAI AIRPORT Name of ship or airline PILIPPHINE AIRLINES Names and addresses of hotels or persons with whom applicant intends to stay Name_MATSUMORI SHIGERU Tel, +8184-923-0721 11-8 2 CHOME OUJICHO FUKUYAMA SHI HIROSHIMA JAPAN, Address, Dates and duration of previous stays in Japan_NONE Your current residential address (if you have more than one address, please list them all) Address SLAMAT KALIAN SESUAI KTP Tel. Mobile No, NO HP. Current profession or occupation and position_STUDENT Nameand address of employer Name LPK WADAH PERINTIS MUDA Tel, (0231)8825939 Address ES” KASUGENGAN KIDUL BLOK KAPLING BARU RT 18 RW 07 KEC. DEPOK KAB. CIREBON ress,*Partner's profession/occupation (or that of parents, if applicant is a minor): NONE. EEE Guarantor or reference in Japanease provide deta ofthe guarantor the pion tobe vittedn Japan) Name NONE : Tel Address ines a Date of birth Sex: Male [] Female [] _. DaiionnveaT Relationship to applicant. Profession or occupation and position Nationality and immigration status Inviter in Japangreasewritesameas above! theivitng patson andthe guarantor are the ame) Name. NONE Tel. Address Date of birth DayiinontyVear Relationship to applicant Profession or occupation and position Nationality and immigration status *Remarks/Special circumstances, if any Have you ever: @ been convicted of a crime or offence in any country? vesE) @ been sentenced to imprisonment for 1 year or more in any countiy?** vesD) @ been deported or removed from Japan or any country for overstaying your visa or violating any law or regulation? ye @ been convicted and sentenced for a drug offence in any country in violation of law concerning narcotics, marijuana, opium, stimulants or psychotrople substances?™* ves] he ‘© engaged in prostitution orn the intermediation or solicitation of a prostitute for other Persons, or in the provision of a place for prostitution, or any other activity directly . Connected to prostitution? ve" & © committed trafficking in persons or incited or aided another to commit such an offence? ve] * Please tick “Yes” ifyou have received any sentence, even ifthe sentence was suspended, Ifyou answered “Yes” to any of the above questions, please provide relevant details. “Thereby deciare thatthe statement given above Is true and correct. understané that immigration status and period of stay to be granted are decided by the Japanese immigration authorities ypon my arrival. understand that possession ofa Visa does not entitle the beorer to enter Japan upon arval at por of entry ifhe or she is found inadmissbl.” “hereby consent to the provision of my personal information (by an accredited travel agent within ts capacty of representing my vsa application) tothe Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee tothe Japanese embassy/consulate-general, when such paymentis necessary.” TIO Date of application, Signature of applicant AAMA LewckAp BaF “Telenor mandatory to complete these Roms ‘Any personal information gathered in this application as wel as addtional information submited forthe visa application (hereinafter referred toas "Retained Personal Information’ will be angled appropriately in accordance with the Acton the Protection of Personal information Held by Administrative Organs (Act No. 58 of 2003, hereinafter, “the Act) Retained Personal Information will only be used for the purpose of processing the visa application and to the extent necessary forthe purposes statedin Article 8of the Act.