"Indonesian Visa Application Form for Single Visit or Multiple Entry - Embassy of the Republic of Indonesia" - Buenos Aires, Argentina

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Mariscal Ramon Castilla 2901
EMBASSY
Buenos Aires
Phone : (11) 4807-2211
OF THE REPUBLIC OF
Fax No.: (11)4802-4448
INDONESIA
BUENOS AIRES, ARGENTINA
VISA APPLICATION FORM FOR SINGLE VISIT OR MULTIPLE ENTRY
1.
Full Name of Applicant
:
Male / Female
-------------------------------------------------------
Place and date of birth
:
-----------------------------------------------------------------------
2.
Nationality
:
-----------------------------------------------------------------------
Passport Number / Travel Documents
:
-----------------------------------------------------------------------
Place and date of issuance
:
-----------------------------------------------------------------------
Valid Until
:
-----------------------------------------------------------------------
3.
Entry Permit / Visa to another country
:
-----------------------------------------------------------------------
Number
:
-----------------------------------------------------------------------
Place and date of issue
:
-----------------------------------------------------------------------
Expiration date
:
-----------------------------------------------------------------------
4.
Name (s) of family members included in applicant's passport who are applying for visa.
[ Full name, family relationship, sex and date of birth.]
N a m e
Family Relationship
Date of birth
Male/Female
a.
b.
c.
5.
Occupation/position
:
------------------------------------------------------------------------
Name of Firm of employment
:
------------------------------------------------------------------------
Address
:
------------------------------------------------------------------------
Postal Code :
Phone :
Home address
:
------------------------------------------------------------------------
Postal Code :
Phone :
Name of reference in Indonesia
:
------------------------------------------------------------------------
Address of reference
:
------------------------------------------------------------------------
Do you have a letter of invitation
:
(please attach copy)
--------------------------------------------------
6.
Purpose of visit to Indonesia :
(Please circle one according to the nature of your visit).
Governmental Visit
Business Visit
Social or Cultural Visit
1. Government of Argentina -
5. Industrial
13. Social
Government of Indonesia
6. Commercial
14. Health and Medical
2. International Organization -
7. Agriculture
15. Educational
Government of Indonesia
8. Transport and Communication
16. A r t s
3. Private Sector Government of
9. Public Works and Public Utilities
17. Sports
Indonesia.
10. Religious
18. Family Visit
4. Individuals - Government of
11. Press and Public Communication
19. Tourism
Indonesia
12. Promotion Visit
20. Study
21. O t h e r s
Type of Visa Requested :
(Please circle accordingly)
01. Single Entry Visa
02. Multiple Entry Visa
03. Transit Visa
Length of intended stay in Indonesia
:
---------------------------------------------
Port and date of Entry
:
---------------------------------------------
Place to be visited in Indonesia
:
---------------------------------------------
Mariscal Ramon Castilla 2901
EMBASSY
Buenos Aires
Phone : (11) 4807-2211
OF THE REPUBLIC OF
Fax No.: (11)4802-4448
INDONESIA
BUENOS AIRES, ARGENTINA
VISA APPLICATION FORM FOR SINGLE VISIT OR MULTIPLE ENTRY
1.
Full Name of Applicant
:
Male / Female
-------------------------------------------------------
Place and date of birth
:
-----------------------------------------------------------------------
2.
Nationality
:
-----------------------------------------------------------------------
Passport Number / Travel Documents
:
-----------------------------------------------------------------------
Place and date of issuance
:
-----------------------------------------------------------------------
Valid Until
:
-----------------------------------------------------------------------
3.
Entry Permit / Visa to another country
:
-----------------------------------------------------------------------
Number
:
-----------------------------------------------------------------------
Place and date of issue
:
-----------------------------------------------------------------------
Expiration date
:
-----------------------------------------------------------------------
4.
Name (s) of family members included in applicant's passport who are applying for visa.
[ Full name, family relationship, sex and date of birth.]
N a m e
Family Relationship
Date of birth
Male/Female
a.
b.
c.
5.
Occupation/position
:
------------------------------------------------------------------------
Name of Firm of employment
:
------------------------------------------------------------------------
Address
:
------------------------------------------------------------------------
Postal Code :
Phone :
Home address
:
------------------------------------------------------------------------
Postal Code :
Phone :
Name of reference in Indonesia
:
------------------------------------------------------------------------
Address of reference
:
------------------------------------------------------------------------
Do you have a letter of invitation
:
(please attach copy)
--------------------------------------------------
6.
Purpose of visit to Indonesia :
(Please circle one according to the nature of your visit).
Governmental Visit
Business Visit
Social or Cultural Visit
1. Government of Argentina -
5. Industrial
13. Social
Government of Indonesia
6. Commercial
14. Health and Medical
2. International Organization -
7. Agriculture
15. Educational
Government of Indonesia
8. Transport and Communication
16. A r t s
3. Private Sector Government of
9. Public Works and Public Utilities
17. Sports
Indonesia.
10. Religious
18. Family Visit
4. Individuals - Government of
11. Press and Public Communication
19. Tourism
Indonesia
12. Promotion Visit
20. Study
21. O t h e r s
Type of Visa Requested :
(Please circle accordingly)
01. Single Entry Visa
02. Multiple Entry Visa
03. Transit Visa
Length of intended stay in Indonesia
:
---------------------------------------------
Port and date of Entry
:
---------------------------------------------
Place to be visited in Indonesia
:
---------------------------------------------
Previous visa for Indonesia granted to the applicant
:
---------------------------------------------
Type
:
---------------------------------------------
Number
:
---------------------------------------------
Place and date of issue
:
---------------------------------------------
Place and date of previous entry to Indonesia
:
---------------------------------------------
7.
Has your application for Indonesian Visa ever been denied
:
---------------------------------------------
Have you ever been ordered to leave Indonesia
:
---------------------------------------------
Have you ever been arrested or convicted
:
---------------------------------------------
8.
Other information which will be useful in considering this application:
a.
Are you in possession of other country’s legal and valid
:
Immigration documents
---------------------------------------------
b.
Number of return / through ticket
:
---------------------------------------------
Airline Company
:
---------------------------------------------
Place and date of issue
:
---------------------------------------------
:
Expiration date
---------------------------------------------
I hereby to declare that:
1. All the statements I have given above are true and correct
2. I am fully aware even though I possess a valid visa to enter Indonesia, entering the Indonesian territory will
remain at the discretion of the Immigration Authorities at the port of entry.
I am also aware that:
1. During my visit to Indonesia I will refrain from:
a. Engaging in any occupation in any institution - either being paid or unpaid
b. Staying beyond the duration of Visa
2. Failing to comply with the above requirements, I will be liable to prosecution or expulsion.
Completed at: _______________
Date: ____________
Signature of Applicant
(Same as in passport)
(PHOTOGRAPH)
3 BY 4 cm
_____________________
Full name printed: ______________________
FOR OFFICIAL USE ONLY
SP. NO.:
1.
Telah diberikan visa atas kuasa sendiri
Macam Visa
:
Nomor Visa
:
Lamanya diizinkan tinggal di Indonesia
:
Tanggal pemberian visa
:
2.
Ijin Dirjenim no.
:
Buenos Aires,
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