EMBASSY OF THE REPUBLIC OF INDONESIA

EMBASSY OF THE REPUBLIC OF INDONESIA
Nad Budankami II/7, 150 21 Praha 5
Czech Republic
VISA APPLICATION FORM
Application Number
/
7S/
I. GENERAL
Length of Stay in Indonesia
Type of Visa
Photograph
:
:
Transit
Single Visit
:
Multiple Visit
Limited Stay/long stay
Tourism
Convention
Family visit
Sports
Study
Arts
Commercial
Others
work
Joint Family
TRANSIT
PURPOSE
FOR TRANSIT
PURPOSE
Country of Destination
:
Place of Departure
Airline Company
:
:
SHORT
For
Visit STAY
Purpose
Purpose of visit
:
Place of visit
:
Airline company
:
LIMITED/LONG STAY VISA
Days
Social
Purpose of long stay
Address in Indonesia
:
City
:
Povince
Province
Phone Number
:
:
POINT OF ENTRY IN INDONESIA
:
:
DATE OF ENTRY
:
II. PERSONAL DATA
First Name
:
Middle Name
:
Family/Surname
:
Sex
:
Male
Female
Marital Status
:
Married
Single
Place of Birth
:
Date of Birth
:
Nationality
:
Address
:
City
Province/State
:
:
Phone Number
:
Profession
:
Professional
Goverment
Businessman
:
Student
Housewife
Others
Name of Company/Institution/School
:
Address
:
:
City
:
Province/State
:
Phone Number
:
(DD-MM-YYYY)
(DD-MM-YYYY)
Others
III. PASSPORT
PASSPORT INFORMATION
INFORMATION
III.
Passport/Travel Document Number
:
Place of Issue
:
Date of Issue
:
Date of Expiry/Valid Until
:
Type of Passport*
:
(DD-MM-YYYY)
(DD-MM-YYYY)
Personal
Family
Please complete this section if your children included on your passport/travel document are travelling with you :
No
Relatives
Sex
Date of birh (DD-MM-YY)
Name
2. Wife
Please use this code:
Relation(s)
:
1. Husband
2. Wife
Sex
:
F : Female
M: Male
IV. SPONSOR
SPONSORSHIP
IN INDONESIA
IV.
IN INDONESIA
(IF ANY)
Type of sponsor
:
Name of Person/Institution
:
Address
:
City
Province/State
Province/State
::
:
Phone Number
:
3. Child
3. Child
Individual
Government
International Institution
Company
NGO
Others
V. MISCELLANEOUS
OTHER INFORMATION
V.
Have you ever been to Indonesia before ?
Yes
No
Are you in possesion of any others countries's 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
Airline Company
:
Place of Issue of airticket
:
Date of Issue of airticket
:
(DD-MM-YYYY)
Date of Expiry of air ticket
:
(DD-MM-YYYY)
I hereby declare that the statements given above are true and I understand that even if granted a visa,
the admission at the airport remains the discretion of the immigration authorities in Indonesia
Applicant's Signature
Prague,
(DD-MM-YYYY) Date
Important Note :
*To be completed with one original photograph attached (passport size)
*Applicant's original signature is required
*Passport must be valid for at least six month on arrival in Indonesia