DIPLOMATIC / SERVICE VISA APPLICATION FORM
SUBMIT TO THE INDONESIAN REP. IN  
Duration of stay in Indonesia *
Type of Visa *
Type of Entries *
Purpose of Visa *

For Transit Visa
Country/City of Embarkation
Next Destination
Address in Indonesia
Name of Institution / Company *
Address*
City*
Phone Number *  
Purpose of Visit*
For Limited Stay Visa
Purpose Limited Stay*


PERSONAL DATA
Given Name * Sex*  
Middle Name* Marital Status  
Surname*
Place of Birth * Date of Birth *
Nationality* Address*
City Province
Postal Code
Telephone* Email*
Fax Mobile/Cellular

PARENT INFO
Name of Father Profesion
Name of Mother Profesion

PROFESSION
Profession* Current Position
Institution Name* Institution Address*
City Province
Postal Code Country
Company's Phone Number * 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.



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

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?  
If Yes, Date of Visit
Purpose of Visit
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?  
Do you have health problem?  
If Yes, give detail
Have you been previously posted abroad?  
First last posting abroad
Second last posting abroad

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