"Indonesian Visa Application Form - the Consulate General of the Republic of Indonesia" - Cape Town, Western Cape, South Africa

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Date
:
(DD-MM-YYYY)
Photograph
I. GENERAL
4X6
Length of Stay in Indonesia
:
Day(s)
Month
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
Purpose of Visit
:
Tourism
Convention
Family Visit
Sport
Study
Arts
Commercial
others
Country Of Destination
:
Place of Visit
:
Flight/Vessel Name
:
For Limited Stay Purpose
Purpose of limited Stay
:
Work
Joint family
Social
Others
Address in Indonesia
:
City
:
Province
:
Date
:
(DD-MM-YYYY)
Photograph
I. GENERAL
4X6
Length of Stay in Indonesia
:
Day(s)
Month
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
Purpose of Visit
:
Tourism
Convention
Family Visit
Sport
Study
Arts
Commercial
others
Country Of Destination
:
Place of Visit
:
Flight/Vessel Name
:
For Limited Stay Purpose
Purpose of limited Stay
:
Work
Joint family
Social
Others
Address in Indonesia
:
City
:
Province
:
-
-
Phone Number
:
Port of entry into Indonesia
:
Date of entry
:
(DD-MM-YYYY)
II. PERSONAL DATA
First Name
:
:
Middle Name
Family Name
:
Sex
:
Male
Female
Marital Status
:
Married
Single
Place of Birth
:
Date of Birth
:
(DD-MM-YYYY)
Nationality
:
Address
:
City
:
Province/State
:
- -
Phone Number
:
Occupation/Position
:
Professional
Government
Sales
Student
Housewife
others
Name of Company
:
Address
:
City
:
Province/State
:
-
-
Phone Number
:
III. PASSPORT INFORMATION
Passport/Travel Document Number
:
Place of Issue
:
Date of Issue
:
(DD-MM-YYYY)
Date of Expire
:
(DD-MM-YYYY)
Type of Passport
:
Personal
Family
*Fill, if Type Passport Family:
No.
Relative(s)
Sex Date of Birth (DD-MM-YYYY)
Name:
*(Relative(s): 1= Husband, 2=Wife, 3=Child)
*(Sex: F= Female, M=Male)
IV. SPONSORSHIP IN INDONESIA
Type of Sponsor
Individual
Government
International Institution
:
Company
NGO
others
Name Company
:
Address
:
City
:
Province/State
:
-
-
Phone Number
:
V. MISCELLANEOUS
Have you ever been to Indonesia?
:
Yes
No
Are you in possession of any other countries travel document?
:
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/Airline Company:
Place of Issue
:
Date of Issue
:
(DD-MM-YYYY)
Date of Expire
:
(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 arirport remains the discretion of the Immigration authorities in Indonesia.
Applicant’s Signature
………………
(DD-MM-YYYY)
*To be Complete in duplicate with two photographs attached.
*Passport must be valid at least six months.