Form C

(See rule 14)

ARRIVAL REPORT OF FOREIGNER IN HOTEL
[To be completed in duplicate]

1. Name and address of the Hotel or other …Kzone Homestay……...……

Premises, where accommodation has been ……………….…………......
Provided for reward/on payment …………………………….…………..
2. Phone / Mobile No. of
The hotel/place of stay ……9886516201……………………………………..
3. Name of foreign visitor in full (as given in passport)
D E N N Y S E T Y A W A N

4. Date of Birth (dd/mm/yy) 0 3 0 9 9 4

5. Address in country where residing permanently

J A L A N D I E N G A T A S
P E R U M A U S T I N V I L L E
M A L A N G

6. Address / Reference in India

U P P E R T O P K H A N A
T R I P A I L I N K R O A D
K A L I M P O N G

7. Nationality I N D O N E S I A8. Passport No: C 5 7 7 0 0 5 0

9. Place of issue of 10. Date of issue of 1 1 0 1 2 0
Passport MALANG Passport (dd/mm/yy)
11. Valid till 1 1 0 1 2 5
(dd/mm/yy)
12. Visa No: V K 9 3 8 9 4 0 1 13. Date of Issue 1 5 1 2 2 1

(dd/mm/yy)
14. Valid Till 1 4 0 6 2 2 14. Type of Visa T O U R I S T
(dd/mm/yy)
16. Place of Issue D E N P A S A R
17. Arrive from B A N G A L O R E
18. Date of Arrival in India (dd/mm/yy) 1 8 0 3 2 2

19. Date of Arrival in Hotel / Premises 2 8 0 4 2 2

20. Time of Arrival 1 0 P M

21. Intended duration of stay in Hotel ( No: of Days). 1 0

22. Whether employed in India (tick √ in appropriate box)

23. Purpose of Visit (tick √ in appropriate box)

Business Transit Official Employment Education Conference

Visit Medical Religion Leisure Sport Tourist

x

24. Next Destination / Proceeds to

D R E P U N G G O M A N G
24. Contact / Phone No.( In India.)

9 5 9 1 5 9 3 3 0 1
26. In Country where permanently residing.
0 8 1 3 1 2 4 1 4 6 4 9

Note: Please ensure that no Column is left blank / complete.

➢ In case web camera / digital camera is not available, photocopy of the
photograph in the Passport may be enclosed.

Manager’s Signature
Name & Address