CONSULATE GENERAL OF THE REPUBLIC OF INDONESIA MUMBAI ...

1 I. GENERALL ength of Stay in INDONESIA : Day(s)Month(s)Year(s)Type of Visa:TransitSingle VisitMultiple VisitLimited StayFor Transit PurposeCountry of Destination:Port of Departure:Flight/Vessel Name:For Visit PurposeType of Visa:TourismConventionFamily VisitSportsStudyArtsCommercialOthersPlac e(s) of visit:Flight/Vessel Name:For Limited Stay PurposePurpose of Limited Stay:WorkJoint FamilySocialOthersAddress in INDONESIA :City:Province:Phone Number:Port of Entry into INDONESIA :Date of enty: (DD-MM-YYYY)II. PERSONAL DATAF irst Name:Middle Name:Family/Surname:Sex:FemaleMaleMarita l Status:MarriedSinglePlace of Birth:Date of Birth (DD-MM-YYYY)Nationality:Address:City:Pro vince/State:Phone Number:Occupation/Designation:Profession alGovernmentSalesStudentHousewifeOthers, Pls.

2 Specified:Name of Company:Address:City:Province/State:Phon e Number:Photograph4 cm X 6 cmCONSULATE GENERAL OF THE REPUBLIC OF INDONESIAMUMBAI - INDIA19, Altamount Road, Cumballa Hill, MUMBAI - 400 026. INDIATel.: (+91-022) 2351 1678 / 2353 09 40 / 2353 09 00 Fax : (+91-022) 2351 09 41 / 2351 58 62E-mail: Web : Date of Submitting application : _____::III. PASSPORT INFORMATIONP assport/Travel Doc. Number:Place of Issue:Date of Issue (DD-MM-YYYY)Date of Expiry (DD-MM-YYYY)Type of Passport *:PersonalFamilyNo Relative(s)* Sex Date of Birth (DD-MM-YYYY)Name----* (Relative: 1=Husband, 2=Wife, 3=Child)* (Sex: F=Female, M=Male)IV.

3 SPONSORSHIP IN INDONESIAType of Sponsor:IndividualGovernmentInternationa l InstitutionCompanyNGOO thersName of Company:Address:City:Province/State:Phon e Number:V. MISCELLANEOUSHave you ever been to INDONESIA before?:YesNoAre you in possession of any other countries' travel documents?:YesNoDo you have previous visa to enter INDONESIA ?:YesNoHave your visa application been denied before?:YesNoHave you ever been forced to leave INDONESIA ?:YesNoHave you ever committed a crime or any offence?:YesNoReturn/Through Ticket/Airline:Place of Issue:Date of Issue (DD-MM-YYYY)Date of Expiry (DD-MM-YYYY)I hereby declare that the statements given above are true and I understand that even if granted a visa, admission atthe airport remains at the discretion of the Immigration authorities in 's Signature ONLY:Completed at:Date: (DD-MM-YYYY)* Signature found made other than applicant could be rejection of visa application;* To be completed in duplicate with two photographs attached.

4 * Passport must be valid at least for six OFFICE USE ONLY DATE.