"Indonesian Visa Application Form - the Embassy of the Republic of Indonesia" - Washington, D.C.

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The Embassy of The Republic of Indonesia in Washington D.C.
2020 Massachusetts Avenue NW, Washington, DC 20036
Phone.+1 (202) 775-5200,Fax. +1 (202) 775-5365 ,Email. infokonsuler@embassyofindonesia.org
Registration Number :
VISA APPLICATION FORM
I. GENERAL
Length of Stay in Indonesia:
Day(s)
Month(s)
Year(s)
Type of Visa:
Transit
Single Visit
Multiple Visit
Limited Stay
For Transit Purpose
Country of Destination:
Port of Departure:
Flight/Vessel Name:
For Visit Purpose
Tourism
Convention
Family Visit
Sport
Study
Arts
Purpose of Visit:
Commercial
Other
Country of Destionation:
Place of Visit:
Flight/Vessel Name:
For Limited Stay Purpose
Purpose of Limited Stay:
Work
Joint Family
Social
Other
Address in Indonesia:
City:
Province:
Phone Number:
Port of Entry into Indonesia:
Date of Entry:
-
-
(DD-MM-YYYY)
II. PERSONAL DATA
First Name:
Middle/Initial:
Last Name:
Sex:
Male
Female
Marital Status:
Single
Married
Place of Birth:
Date of Birth:
-
-
(DD-MM-YYYY)
Nationality:
Address:
City:
State:
Zip:
Phone Number:
-
-
The Embassy of The Republic of Indonesia in Washington D.C.
2020 Massachusetts Avenue NW, Washington, DC 20036
Phone.+1 (202) 775-5200,Fax. +1 (202) 775-5365 ,Email. infokonsuler@embassyofindonesia.org
Registration Number :
VISA APPLICATION FORM
I. GENERAL
Length of Stay in Indonesia:
Day(s)
Month(s)
Year(s)
Type of Visa:
Transit
Single Visit
Multiple Visit
Limited Stay
For Transit Purpose
Country of Destination:
Port of Departure:
Flight/Vessel Name:
For Visit Purpose
Tourism
Convention
Family Visit
Sport
Study
Arts
Purpose of Visit:
Commercial
Other
Country of Destionation:
Place of Visit:
Flight/Vessel Name:
For Limited Stay Purpose
Purpose of Limited Stay:
Work
Joint Family
Social
Other
Address in Indonesia:
City:
Province:
Phone Number:
Port of Entry into Indonesia:
Date of Entry:
-
-
(DD-MM-YYYY)
II. PERSONAL DATA
First Name:
Middle/Initial:
Last Name:
Sex:
Male
Female
Marital Status:
Single
Married
Place of Birth:
Date of Birth:
-
-
(DD-MM-YYYY)
Nationality:
Address:
City:
State:
Zip:
Phone Number:
-
-
III. P
ASSPORT INFORMATION
Passport/Travel Document Number:
Place of Issue:
Date of Issue:
Date of Expired:
IV. SPONSOSHIP IN INDONESIA
Type of Sponsor:
Individual
Government
International Institution
Company
NGO
Others
Name of Sponsor:
Address:
City:
State:
Zip:
Phone Number:
-
-
V. MISCELLANEOUS
Have You ever been to Indonesia before?
Yes
No
Are You in possession of any other countries travel documents?
Yes
No
Do You have previous visa to enter Indonesia?
Yes
No
Have Your visa application been denied before?
Yes
No
Have You ever been forced to leave Indonesia?
Yes
No
Have You ever been committed a crime or any offence?
Yes
No
Return/Through Ticket:
Place of Issue:
Date of Issue:
-
-
(DD-MM-YYYY)
Date of Expired:
-
-
(DD-MM-YYYY)
I hereby declare that the statements given above are true and I understand that even if granted a visa,
admission at the airport remains the discretion of the Immigration authorities in Indonesia.
Applicant’s Signature
_____________________ , _____ - _____ - __________ (Place, DD-MM-YYYY)
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