"Indonesian Visa Application Form - Embassy of the Republic of Indonesia" - City of Ottawa, Ontario, Canada

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EMBASSY OF THE REPUBLIC OF INDONESIA
55 PARKDALE AVENUE, OTTAWA, ON K1Y 1E5
VISA APPLICATION FORM
This form is completed on your computer
or in CAPITAL LETTERS
TYPE OF VISA REQUESTED
1 (one) Photo
Single‐entry 
Can only be used for one entry, valid for 90 days after the date of issuance 
 
with a maximum stay of 60 days
Multiple‐entry 
Can be used for multiple entry  within 1 year with a  Maximum stay of 60 
staple or glue 
 
days per visit
 
the photo here
Limited Stay  
Needs authorization letter from Directorate General of Immigration in 
 
Jakarta, Indonesia
Diplomatic and Special / Service Passport 
 
Single entry with a maximum stay of 30 days
1
Applicant’s Full Name as mentioned in your passport
Family Name: 
Given Names:  
Gender: 
        Male                 Female 
Place of Birth (City‐Country): 
Date of Birth (DD/MM/YYYY): 
Marital status : 
  Married     Single     Other:  
Nationality: 
Passport Number: 
Type of Passport:  
       Ordinary                Diplomatic / UNPL     
                                       Special/service 
Passport Place of Issuance: 
Passport Date of Issue (DD/MM/YYYY): 
Passport Date of Expire (DD/MM/YYYY): 
2
Applicant’s home address in Canada
Number and name of Street 
Apt. / Unit No. 
Home Phone: Area code / Number 
City  
Province 
Postal Code 
Mobile:   Area code / Number 
Email address :  
3
Full Time Occupation / Student
Name of Company / Educational Institution; 
 Position:  
 
Number and name of Street : 
Work  Phone:   Area code / Number 
City  
Province 
Postal Code 
Mobile:   Area code / Number 
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EMBASSY OF THE REPUBLIC OF INDONESIA
55 PARKDALE AVENUE, OTTAWA, ON K1Y 1E5
VISA APPLICATION FORM
This form is completed on your computer
or in CAPITAL LETTERS
TYPE OF VISA REQUESTED
1 (one) Photo
Single‐entry 
Can only be used for one entry, valid for 90 days after the date of issuance 
 
with a maximum stay of 60 days
Multiple‐entry 
Can be used for multiple entry  within 1 year with a  Maximum stay of 60 
staple or glue 
 
days per visit
 
the photo here
Limited Stay  
Needs authorization letter from Directorate General of Immigration in 
 
Jakarta, Indonesia
Diplomatic and Special / Service Passport 
 
Single entry with a maximum stay of 30 days
1
Applicant’s Full Name as mentioned in your passport
Family Name: 
Given Names:  
Gender: 
        Male                 Female 
Place of Birth (City‐Country): 
Date of Birth (DD/MM/YYYY): 
Marital status : 
  Married     Single     Other:  
Nationality: 
Passport Number: 
Type of Passport:  
       Ordinary                Diplomatic / UNPL     
                                       Special/service 
Passport Place of Issuance: 
Passport Date of Issue (DD/MM/YYYY): 
Passport Date of Expire (DD/MM/YYYY): 
2
Applicant’s home address in Canada
Number and name of Street 
Apt. / Unit No. 
Home Phone: Area code / Number 
City  
Province 
Postal Code 
Mobile:   Area code / Number 
Email address :  
3
Full Time Occupation / Student
Name of Company / Educational Institution; 
 Position:  
 
Number and name of Street : 
Work  Phone:   Area code / Number 
City  
Province 
Postal Code 
Mobile:   Area code / Number 
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4
Purpose of Travel
  Tourism 
  Family Visit 
  Study 
  Internship 
  Press & Media  
 
  Film Making 
  Arts 
  Sports  
  Workshop 
  Seminar 
  Conference 
  Business/Commercial    Industry 
  Mining 
  Agriculture 
  Official Visit/Meeting 
  Diplomatic Posting  
  Others: 
5
Length of stay and Flight / Cruise Ship information to and from Indonesia
Length of Stay (days) 
Date of Entry 
City and Port of Entry 
City and Port of Exit 
Date of Exit 
Flight / Cruise Ship Number 
Flight / Cruise Ship Number 
6
Hotel Name and Address in Indonesia (first arrival)
Hotel Name: 
Hotel Address : 
City & Province: 
Phone Number: 
7
Indonesian Sponsor (not applicable to Tourism)
Name of Sponsor 
Sponsor’s Title/Position 
Work  Phone:   Area code / Number 
Name of Company / Institute  
Fax Number : Area code / Number 
City / Province 
Postal Code 
Mobile (if any) : Area code / Number 
8.  Are you in Possession of other Country’s Valid Passport    
If Yes,  Specify the Country:  
  Yes        No 
9
Does any of the following apply to you
Yes
No
Please Specify:
 
 
 
Have you ever travelled to Indonesia 
Has your visa application for Indonesia ever been 
 
 
 
denied  
 
 
 
Have you ever been ordered to leave Indonesia 
Have you ever been arrested or convicted of a 
 
 
 
criminal act?  
Applicant’s Signature and Date  
 
1.
I hereby declare that the statement given above is true and correct to the best
 
of my knowledge.
 
2.
I understand that possession of a Visa does not automatically entitle the
 
bearer to enter Indonesia upon arrival if he or she is found inadmissible.
 
 
3.
I understand that any false or misleading statement may result in permanent
 
refusal of a visa or denial of entry into Indonesia.
                           
 
4.
I am also aware that failing to comply with the above requirements, I will be
  
liable to prosecution or expulsion.
 
Date :  
 
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