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NUMBER DATE I. GENERAL Duration of Stay in Indonesia Type of Visa Day(s) Month(s)
For Transit Visa Country of Destination Place of Departure Flight/Vessel Name For Visit Visa Purpose of Visit
Tourism Study
Convention Arts
Sports Others
Country of Destination Place of Visit Flight/Vessel Name For Limited Stay Visa Purpose of Limited Stay Address in Indonesia City Province Phone Number Port of Entry into Indonesia Date of Entry II. PERSONAL DATA First Name Middle Name Family/Surname Sex Marital Status Place of Birth Date of Birth Nationality Home address in Pakistan City Province/State Phone Number Profession Type of Business Name of Company/Institution Address in Pakistan
Work
Joint Family
Social
Others
(DD-MM-YYYY)
Male Married
-
Female Single
(DD-MM-YYYY)
Student
Housewife
Others
Ill. PASSPORT INFORMATION Passport/Travel Document Number Place of Issue Date of Issue Date of Expiry Type of Passport
(DD-MM-YYYY) (DD-MM-YYYY)
Personal
Family
Name
Please mention if your husband/wife/children are accompanying you and have been entered in your travel document
Relation Sex
(s)
1 F
Husband Female
2 M
Wife Male
Child
Individual Company
Government NGO
Name of Person/Institution Address City Province/State Phone Number V. OTHER INFORMATION Have you ever been to Indonesia before? Are you in possesion of any other countries'travel documents ? Do you have previous visa to enter Indonesia? Has your visa application been refused before? Have you ever been deported from Indonesia? Have you ever committed a crime or any offence? Retum/Through Tickeffirline Company Place of Issue Date of Issue Date of Expiry
No No No No No No
(DD-MM-YYYY) (DD-MM-YYYY)
I hereby declare that the statements given above are true and I understand that even if granted a visa the admission at the airport remains the discretion of the Immigration authorities in Indonesia Applicant's Signature
(DD-MM-YYYY)
FOR OFFICE USE ONLY Index Visa Lamanya Izin Tinggal di Indonesia Kuasa Perwakilan / Ditjenim Hari/Bulan Karachi, a.n. Kepala Perwakilan RI