EMBASSY OF THE REPUBLIC OF INDONESIA. SINGAPORE VISA APPLICATION FORM File Number ATTENTION! Please filn all headings using CAPITAL LETTERS. Your application shall not be processed in case of error omission. Notes: * Tick (W) where appropriate | declare that all data given in this form is complete and true. | am aware that any false statements will lead to my application being fejected or to the annulment of visa already granted and may also render me liable to prosecution under Indonesian Law. | understand that possession of a visa does not entitle its bearer to enter Indonesia. | will not seek compensation if| am refused to enter Indonesia, Full Name Of Applicant (same as in passport) : sex: OM OF Place and Date of Birth Country of Origin Emergency contact of origin Marital Status :OSingle Married — C] Divorce ~~ ] Widowed 2. Nationality Photo Passport Size Passport/ Travel Doc Number: Place of issue Date of issue Valid Until 3. Occupation Name of Firm in Singapore ‘Address of Firm 4. Address in Singapore Contact number and email 5, Number of Entries? Csingle Entry C1 Muttipte Entry Length of Intended stay ___Days:__Months: ___Years Type of Visa?* Visit Visa CTourism [] Business Visit [1 Family/Social Visit 1 study Convention [1 others: Temporary stay Visa Study = Working 1 Join Family TD other(Piease Specity) 6. Where will you be staying in Indonesia?” Ci Relative's Place Hotel For official use Only: Tol: Sponsor CY OT Persetujuan: Dijenim: = OY OT Masa Berlaku Paspor 6bun; OY OF Cokek = OY OT Biya Visa: OY OT Kelengkapan syarat: Lengkap: OY OT ) Petugas Counter Telah diberikan Visa Oi Friend’s Place © Others (Please Specify) Type a ve Son Indeks Visa Name of Reference Nomor Visa Address of Reference ~ Lamanya Tinggat 8, Have you ever entered Indonesia using different passport or name?* OvesOno # wfple(p torr) Have your application for Indonesian Visa ever been denied?* Dyes C1No Have you ever been prohibited from entering Indonesia?* Dyes FNo Disetujl/ Ditolak Have you ever been deported from any country including Indonesia?* (yes CNo Have you ever been arrested or convicted of any criminal act?* O Yes (J No if any of the answer is "YES", please furnish details below: Signature of Applicant Date Pejabat Imigrasi