GENERAL INFO
SUBMIT TO THE INDONESIAN REP. IN  
Duration of stay in Indonesia *
Type of Visa *

For Transit Visa
Country/City of Embarkation
Next Destination
For Visit Visa
Purpose of Visit*
For Limited Stay Visa
Purpose Limited Stay*


Address to Visit in Indonesia
Full Address in Indonesia *
City*
Phone Number *  

Flight/Entry/Exit Info
 
Flight/Vessel Name* Flight Number*
Type of Ticket* Date of Ticket Issued *
Place of Ticket Issued * Date of Ticket Expiry *
Port of Entry Into Indonesia * Date of Entry Into Indonesia*
Port of Exit from Indonesia Date of Exit from Indonesia

PERSONAL DATA
Given Name * Sex*  
Surname* Marital Status  
Place of Birth * Date of Birth *
Nationality*
For non-Sri Lankan or non-Maldivian should have Residence Visa in Sri Lanka or Maldives.
Address*
City Province
Postal Code
Telephone* Email*
Fax Mobile/Cellular

PROFESSION
Profession* Current Position
Company Name* Company Address*
City Province
Postal Code Country
Company's Tlp. * Company's Fax

PASSPORT
Type of Passport *
Passport Number *
Date of Passport's Issue *
Date of Passport's Expiry *
Place of Passport's Issue *

FAMILY MEMBERS
Please mention if your husband/wife/children are accompanying you and have been entered in your travel document
No. Relation Sex Place of Birth Date of Birth Surname Name
1.
2.
3.


SPONSOR/TRAVEL AGENT IN INDONESIA
Type of Sponsor *  
Contact Person of Sponsor*
Title/Position
Name of Company/Institution *    
Address*    
City*  
Telephone*  
Fax/Email


OTHER INFORMATION
Have you ever been to Indonesia before?  
Are you in possesion of any other countries travel documents?  
Do you have previous visa to enter Indonesia?  
Has your visa application been denied before?  
Have you ever been forced to leave Indonesia?  
Have you ever been committed a crime or any offence?  

Uploading Your photograph file (in jpg format and maximum size of 300kb) is required


developed by niams