GENERAL INFO
SUBMIT TO THE INDONESIAN EMBASSY IN  
Duration of stay in Indonesia *
Type of Visa *

For Transit Visa
Country/City of Embarkation
Next Destination
For Visit Visa
Purpose of Visit*
For Limited Stay Visa
Purpose Limited Stay*


Address to Visit in Indonesia
Full Address in Indonesia Detail of Purpose *
City*
Phone Number *  

Flight/Entry/Exit Info
 
Flight/Vessel Name* Flight Number*
Type of Ticket* Date of Ticket Issued *
Place of Ticket Issued * Date of Ticket Expiry *
Port of Entry Into Indonesia * Date of Entry Into Indonesia*
Port of Exit from Indonesia Date of Exit from Indonesia
Flight Number of Exit from Indonesia

PERSONAL DATA
Given Name * Sex*  
Surname* Marital Status  
Place of Birth * Date of Birth *
Nationality*
Address*
City
Province Postal Code
Country  
Phone Number * Email*
Fax Mobile/Cellular

PROFESSION
Profession* Current Position
Company Name* Company Address*
City Province
Postal Code Country
Company's Phone. * Company's Fax

PASSPORT
Type of Passport *
Passport Number *
Date of Passport's Issue *
Date of Passport's Expiry *
Passport Issued by *

FAMILY MEMBERS
Please mention if your husband/wife/children are accompanying you and have been entered in your travel document
No. Relation Sex Place of Birth Date of Birth Surname Name
1.
2.
3.


SPONSOR/TRAVEL AGENT IN INDONESIA
Type of Sponsor *  
Contact Person of Sponsor * Position of Contact Person
Name of Company *    
Address*    
City*  
Telephone* Fax
Do You Have an Invitation/Reference Letter?         


OTHER INFORMATION
1. Have you ever been in Indonesia before?
(if yes please specify when and length of stay)
2. Do you have previous visa to enter Indonesia?  
3. Are you in possession of other country's legal and valid Visa  
(if yes, please specify the country of issuance)
4. Has your application for Indonesian Visa ever been denied?  
5. Have you ever been ordered to leave Indonesia?  
6. Have you ever been arrested or convicted of a criminal act?  

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