VISA APPLICATION FORM EMBASSY OF THE REPUBLIC OF INDONESIA SINGAPORE File Number ATTENTION! Please fil in all headings using CAPITAL LETTERS. Your application shall not be processed in case of error omission Notes: * Tick (\) where appropriate | declare that all data given in this form is complete and true. | am aware that any false statements will lead to my application being rejected or to the annulment of visa already granted and may also render me lable to prosecution under Indonesian Law. | understand that possession ofa visa does not entitle its bearer to enter Indonesia. | will nt seek compensation if| am refused to enter Indonesia, |. Full Name Of Applicant (same as in passport) Place and Date of Birth Country of Origin Emergency contact of origin Marital Status 2. Nationality Passpori/ Travel Doc Number: Place of issue Date of issue 3. Oceupation Name of Firm in Singapore ‘Address of Firm 4, Address in Singapore (for Social & Tourist Visa Only) Contact number and email Valid Until Sex: OM OF Osinge CMaried C1Divorce 2) Widowed 5. Number of Entries?* TiSingle Entry Length of intended stay :_Days:_Months: ‘Type of Visa?* Visit Visa Ci Tourism (C) Business Visit [] Family/Social Visit O study (Convention 0 Others: Temporary stay Visa study = Working 2) Join Family (1 othen(Piease Specify) 6. Where will you be staying in Indonesia?” i Relative's Place CD Hotel CO Friend's Place 7. Telex No. Name of Reference Address of Reference 8. Have you ever entered Indonesia using different passport or name?* Tl Others (Please Specify) (Yes [No Have your application for Indonesian Visa ever been denied?” Dyes L1No Have you ever been prohibited from entering Indonesia?” DYes C]No Have you ever been deported from any country including Indonesia?* Dyes E] No Have you ever been arrested or convicted of any criminal act?* Oyes G1 No if any of the answer is “YES”, please furnish details below: —————— Cc Signature of Applicant Date Photo. Passport Size For official use Only: Tai: Sponsor: OY OT Persetujuan: Ditfenim: = GY OT Masa Bertaku Paspor: buen: = OY OF Ceka: = OY OT Biaya Visa: OY OT Kelengkapan syarat Lengkap: OY OT ) Petugas Counter Telah diberikan Visa Type Indeks Visa: Nomor Visa Lamanya Tinggat HeLa) Disetujui/ Ditolak Pofabat Imigrasi