Spouse Name ‫ﺇﺳﻢ‬ 5 Martial SINGLE ‫ ﺍﻟﺤﺎﻟﺔ‬1

‫ﺍﻟﺰﻭﺟﺔ‬/‫ﺍﻟﺰﻭﺝ‬ Status ‫ﺍﻹﺟﺘﻤﺎﻋﻴﺔ‬

INDONESIAN 6 U KOSASIH (RIP) 2
Critical
Nationality
Place Infrastructure
Of Birth & Coastal ‫ﺍﻟـﺠــﻨـﺴــــــﻴ‬
Protection Authority
‫ﻣـﻜــﺎﻥ‬ Father’s
Nationalit ‫ﺍﻟﺠﻨﺴﻴﺔ ﺍﻷﺏ‬
‫ﺇﺳـــــﻢ‬
‫ ـﺔ ﺍﻟـﻤﻴﻼﺩ‬7 Name
y ‫ﺟﻬﺎﺯ ﺣﻤﺎﻳﺔ ﺍﻟﻤﻨﺸﺂﺕ ﺍﻟﺤﻴﻮﻳﺔ ﻭﺍﻟﺴﻮﺍﺣﻞ‬3
12 AUG 1952
Of BithInfrastructure Permt’s ‫ﻣﻜﺎﻥ‬
Department ‫ ﺗـﺎﺭﻳــﺦ‬8 Place Of BANDUNG
Date ‫ﺍﻟﻤﻬﻨ‬ ‫ﻣـﻜــﺎﻥﺍﻟﻤﻴﻼﺩ‬
‫ﺗﺎﺭﻳﺦ‬
‫ ﺍﻟـﻤـﻴـﻼﺩ ﺷﻌﺒﺔ ﺗﺼﺎﺭﻳﺢ ﺍﻟﻤﻨﺸﺂﺕ‬4
Employer Occupati Date Of
‫ﺍﻟـﻤﻴﻼﺩ‬ Birth ‫ﺍﻟﺤﻴﻮﻳﺔ‬
Occupation ‫ﺍﻟـﻤــﻬــﻨــﺔ‬ Employer ‫ﻣـﻜــﺎﻥ‬
‫ﺍﻟــﻌـﻤـﻞ‬
Nationality INDONESIAN ‫ﺍﻟـﺠـﻨـﺴـﻴﺔ‬ Mother’s DRA CUTIPAH ‫ﺇﺳــــﻢ ﺍﻷﻡ‬
Name
17 JUNE 1958 TASIKMALAYA
Date Of Bith
* ‫ﺗـﺎﺭﻳــﺦ‬ should be hand written in Arabic for ‫ﻣـﻜـﺎﻥ‬
* Arabs nationals & English typing for other
Place OfThe document

Introduction nationalities .

Form
)7( ‫ﻧﻤــﻮﺫﺝ ﺭﻗـــﻢ‬
Applicant’s Details ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺸﺨﺺ‬

Full Name DANIAWAN JUNIANA ‫ﺍﻹﺳـﻢ‬

‫ﺑـﺎﻟﻜــﺎﻣﻞ‬
Nickname ‫ﺇﺳـﻢ‬ Surname ‫ﺇﺳـــﻢ‬
‫ﺍﻟـﺸـﻬــﺮﺓ‬ ‫ﺍﻟـﻌــﺎﺋـﻠـﺔ‬
Previous INDONESIA ‫ﺍﻟﺠﻨﺴﻴﺔ‬ Nationalit INDONESIAN ‫ﺍﻟﺠﻨﺴﻴـﺔ‬
Nationality ‫ﺍﻟﺴﺎﺑﻘﺔ‬ y ‫ﺍﻟـﺤﺎﻟﻴﺔ‬
Place Of Birth BANDUNG ‫ﻣـﻜـﺎﻥ‬ Religion ASLAM ‫ﺍﻟﻤﺬﻫ‬/‫ﺍﻟﺪﻳـﺎﻧـﺔ‬
‫ ﺍﻟﺼــــﻮﺭﺓ‬Photograph ‫ﺍﻟـﻤـﻴﻼﺩ‬ /Doctrine ‫ﺐ‬
(6 X 4) cm
Date Of Entry 30 JUNE 2019 ‫ﺗــﺎﺭﻳـﺦ‬ Date Of 28 JUNE 1991 ‫ﺗــــﺎﺭﻳﺦ‬

Office Tel. ‫ﻫﺎﺗﻒ‬ Current ‫ﺍﻟـﻜﻔﻴـﻞ‬

‫ﺍﻟﻌﻤﻞ‬ Sponsor ‫ﺍﻟﺤــﺎﻟـﻲ‬
Occupation NAVIGATOR ‫ﺍﻟـــﻤـﻬــﻨــﺔ‬ Work ABU DHABI ‫ﻣـﻜــــﺎﻥ‬
Location ‫ﺍﻟـﻌـﻤـﻞ‬
Bank HSBC ‫ﺍﻟﺒــﻨـــــــﻚ‬ Salary AED 3673 ‫ﺍﻟــــﺮﺍﺗـــﺐ‬
Place of Issue TASIKMALAYA ‫ﻣﻜـﺎﻥ‬ Passport C2247974 ‫ﺭﻗﻢ‬
‫ﺍﻹﺻـﺪﺍﺭ‬ No. ‫ﺍﻟﻮﺛﻴﻘﺔ‬/‫ﺍﻟﺠﻮﺍﺯ‬
Expiry Date 21 DECEMBER 2023 ‫ﺗـﺎﺭﻳـﺦ‬ Date Of 21 DECEMBER 2018 ‫ﺗـــﺎﺭﻳـﺦ‬
‫ﺍﻹﻧﺘﻬـﺎﺀ‬ Issue ‫ﺍﻹﺻـﺪﺍﺭ‬
Place Of Issue UNITED ARAB EMIRATES ‫ﻣـﻜـﺎﻥ‬ Residence 784-1991-4694649-5 ‫ﺭﻗـــــﻢ‬
‫ﺍﻹﺻـﺪﺍﺭ‬ No. ‫ﺍﻹﻗـــﺎﻣـﺔ‬
Education ‫ﺍﻟـﻤﺆﻫﻞ‬
‫ﺍﻟﺪﺭﺍﺳﻲ‬
College/Univers ‫ﺍﻟﺠﺎ‬/‫ﺍﻟﻤﺪﺭﺳﺔ‬ Graduatio 2013 ‫ﺗـﺎﺭﻳــﺦ‬
ity ‫ﻣﻌﺔ‬ n ‫ﺍﻟـﺘـﺨــﺮﺝ‬
Place Of Issue BANDUNG ‫ﻣـﻜـﺎﻥ‬ Residence 1.1.05.II.2511 ‫ﺭﻗـــﻢ‬
‫ﺍﻹﺻــﺪﺍﺭ‬ No. ‫ﺍﻹﻗــــــﺎﻣﺔ‬
‫ﻭﺛـﻴـﻘـــﺔـ ﺗــﻌــــﺎﺭﻑـ‬

‫* ﻛـﺘــﺎﺑﺔ ﺍﻟـﻮﺛﻴـﻘـﺔ ﺑــﺨـﻂ ﺍﻟـﻴـﺪ ﺑـﺎﻟﻨﺴﺒﺔ ﻟﻠــﻌــﺮﺏ ﺃﻭ ﻣــﻦ ﺃﺻــﻞ‬

‫ﻋـﺮﺑـﻲ ﺃﻣـﺎ ﺑـﺎﻟﻨﺴﺒﺔ ﻟﻸﺟـﺎﻧـﺐ ﻃﺒـﺎﻋـﺔ ﺍﻟﻮﺛﻴﻘﺔ ﺑﺎﻟﻠﻐﺔ ﺍﻹﻧﺠﻠﻴﺰﻳﺔ‪.‬‬
 Relatives ‫ﺍﻷﻗﺎﺭﺏ‬
# Name ‫ﺍﻹﺳــﻢ‬ Nationality ‫ﺍﻟﺠﻨﺴﻴﺔ‬ Employer ‫ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬
1 SOFYAN RACHMAWAN S.pd INDONESIAN
2 FERDIAWAN INDONESIAN

3 DHILA AGHESTINE C.T INDONESIAN

Friends ‫ﺍﻷﺻﺪﻗﺎﺀ‬
# Name ‫ﺍﻹﺳــﻢ‬ Nationality ‫ﺍﻟﺠﻨﺴﻴﺔ‬ Employer ‫ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬
1 ALI NURMAN INDONESIAN
2 M TAUFIK AKBAR INDONESIAN

3 RIO AGUSTINO INDONESIAN

Residence Address ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺴﻜﻦ‬

Street ‫ﺍﻟــﺸــــﺎﺭﻉ‬ Location ‫ﺍﻟﻤﻨـﻄــﻘــﺔ‬
Bldg. No. ‫ﺭﻗﻢ‬ Landlord ‫ﺇﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫ﺍﻟﺒﻨﺎﻳﺔ‬/‫ﺍﻟﻤﻨﺰﻝ‬
Flat No. ‫ﺭﻗﻢ ﺍﻟﺸﻘﺔ‬ Floor ‫ﺍﻟـﻄـــﺎﺑــﻖ‬
Mobile No. ‫ﺍﻟﻬﺎﺗﻒ‬ Telephone ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬
‫ﺍﻟﻤﺘﺤﺮﻙ‬
P.O.Box ‫ﺻﻨـﺪﻭﻕ‬ Pager ‫ﺭﻗﻢ ﺍﻟﻨﺪﺍﺀ‬
‫ﺍﻟـﺒـﺮﻳﺪ‬ ‫ﺍﻟﻌﺎﻡ‬
‫ ﺍﻷﻋﻤﺎﻝ ﺍﻟﺘﻲ ﻣﺎﺭﺳﺘﻬﺎ ﺩﺍﺧﻞ ﺍﻟﺪﻭﻟﺔ‬UAE in Occupation Previous

1
2

Countries you visited ‫ﺍﻟﺪﻭﻝ ﺍﻟﺘﻲ ﺳﺒﻖ ﻟﻚ ﺯﻳﺎﺭﺗﻬﺎ‬

1
2
3

Countries you worked with ‫ﺍﻟﺪﻭﻝ ﺍﻟﺘﻲ ﺳﺒﻖ ﻟﻚ ﺍﻟﻌﻤﻞ ﺑﻬﺎ‬

1
2
3

Car Information ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﺮﻛﺒﺔ‬

Place Of Regis. ‫ﺟﻬﺔ‬ Car Brand ‫ﻧﻮﻉ ﺍﻟﻤﺮﻛﺒﺔ‬

‫ﺍﻟﺘﺮﺧﻴﺺ‬
Plate Color ‫ﻟــــﻮﻥ ﺍﻟﻠﻮﺣﺔ‬ Plate No. ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬
Place Of Issue ‫ﻣﻜﺎﻥ ﺍﻹﺻﺪﺍﺭ‬ License ‫ﺭﻗﻢ ﺭﺧﺼﺔ‬
No. ‫ﺍﻟﻘﻴﺎﺩﺓ‬
Expiry Date ‫ﺍﻟﻬﺎﺗﻒ‬ Date Of ‫ﺗﺎﺭﻳﺦ ﺍﻹﺻﺪﺍﺭ‬
‫ﺍﻟﻤﺘﺤﺮﻙ‬ Issue ‫ﻻ‬ ‫ ﻧﻌﻢ‬:‫ﻫﻞ ﺳﺒﻖ ﻟﻚ ﺍﻟﻌﻤﻞ ﻓﻲ ﺍﻟﻤﺠﺎﻝ ﺍﻟﻌﺴﻜﺮﻱ‬
Have you served in the Military Service:YesNo

Level Of ‫ﻧــــﻮﻉ‬ Country ‫ﺇﺳﻢ ﺍﻟﺪﻭﻟﺔ‬

Service ‫ﺍﻟﺨﺪﻣﺔ‬
Datecertify
ersigned that all the above statement are correct &‫ﻣــــﺪﺓ‬
Of Service Rank
complete. ‫ﺃﺗﻌﻬﺪ ﺃﻧﺎ ﺍﻟﻤﻮﻗﻊ ﺃﺩﻧﺎﻩ ﺑﺄﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ ﺍﻟﻮﺍﺭﺩﺓ ﺑﻬﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ‬
‫ﺍﻟﺮﺗﺒﺔ‬
‫ﺍﻟﺨﺪﻣﺔ‬
‫ﺻﺤﻴﺤﺔ ﻭﻛﺎﻣﻠﺔ‬.

e following with this statement: Photographs & Passport Copy. ‫ﺍﻟﻤﺮﻓﻘﺎﺕ ﺍﻟﻤﻄﻠﻮﺑﺔ‬:
D 31 AUG 2019 ‫ﺍﻟﺘﺎﺭ‬ Signatu ‫ﺍﻟﺘﻮﻗﻴ‬ Name DANIAWAN JUNIANA
‫ﺍﻟﺴﻔﺮ‬ ‫ﺷﻤﺴﻴﺔ ﻭ ﺻﻮﺭﺓ ﺟﻮﺍﺯ‬
‫ﺻﻮﺭ ﺍﻹﺳـــﻢ‬.
at ‫ﻳﺦ‬ re ‫ﻊ‬
e