The Embassy Of Korea

Jalan Jenderal Gatot Soebroto Kav 57

Jakarta Selatan
Dear Sir/Madam,
We the undersign,
Name
Place and Date of Birth
Address
Passport Number
Name
Place and Date of Birth
Addres
Passport Number

: Achmad Faisal S.SOS

: Samarinda 27 juni 1964
: jalan mas penghulu RT 42 kelurahan Masjid Samarinda Seberang Samarinda
Kalimantan timur
:: Lik Tituk Suwardjijani
: Jember, 10 Januari 1971
: jalan mas penghulu RT 42 kelurahan Masjid Samarinda Seberang Samarinda
Kalimantan timur
:-

Give Permission to my daughter

Name
Place and Date of Birth
Addres
Passport Number

: Mega Aryani
: Samarinda, 24 april 1991
: jalan mas penghulu RT 42 kelurahan Masjid Samarinda Seberang Samarinda
Kalimantan timur
:
: A 9359550

To visit South Korea from on 3 December 2014 to 08 December 2014, to participate in Panorama Tour
accompanied by Achmad Faisal S.sos

Samarinda, 01 november 2014

Achmad Faisal S. SOS

Father

Lik Tituk Suwardjijani

Mother