Form for granting Power of Attorney English text

I hereby authorize the following person to act as an agent on my behalf in relation to my application, cf. 12 of the Public Administration Act.
Surname, first name of your agent (name of the person you authorize to act on your behalf)

Anna N. Knutsen
The agents address: (contact address) Tors veg 9d Telephone +47 481 42 878 Mobile phone +47 481 42 878 Postal code 7032 E-mail visa@ises2013.com Place / country Trondheim/Norway Fax

Information about yourself (person granting the power of attorney):

Surname, first name

Wibawa, I Gusti Agung Aditya Surya

Date of birth January, 20 th 1993 Place and date Semarang, May 8th 2013 DUF number / reference number (if you have it available) Signature

Enclose a copy of an ID document belonging to the person granting the power of attorney (passport or other acceptable ID document) with a visible signature, in the box below.