EMBASSY OF THE REPUBLIC OF INDONESIA AMBASADA REPUBLICII INDONEZIA BUCHAREST, ROMANIA BUCURESTI, ROMANIA

Visa Application Form Formular pentru viza

Application No Date I. GENERAL

Type of visa Tipul de viza

: :

Diplomatic Diplomatic Business Afaceri

Service de serviciu Transit Tranzit Multiple Mai multe Study de studiu Sports Sport

Social Culture Social si Cultural

Tourist Turistic

COLOUR PHOTO FOTOGRAFIE COLOR 3.5 X 4.5 CM

Number of entries Numarul de intrari Purpose of Visit Scopul calatoriei

Single Singura Tourism Turistic Arts Arta

Family Visit Vizitarea familiei Commercial Comercial

Convention Conferinta Others : Altele

..

FOR OFFICIAL USE ONLY NUMAI PENTRU UZ OFICIAL

Dokumen pendukung:

Destination(s) Destinatie (i) Duration of stay Durata sederii Date of entry Data intrarii Day(s) Zile Day Zile Month(s) Luni Month Luni Year(s) Ani Year Ani

Valid Passport Tiket Undangan Akomodasi Asuransi Bukti Rekening Izin Ditjen Imigrasi Lain-lain:

Visa:

Ditolak Disetujui

II.

PERSONAL DATA / DATE DESPRE DUMNEAVOASTRA

Tipe & Indeks Visa: First name Prenumele Surname Numele Gender Sexul Place of birth Locul nasterii Date of birth Data nasterii Nationality Nationalitatea Home address Adresa de domiciliu Phone number Numar de telefon Profession Profesia
Professional Angajat Housewife Casnica Government Businessman Student Functionari Om de afaceri Student Guvernamental Other (please specify) : Altele (va rugam sa specificati) ..

B M F Marital status Starea civila Married Casatorit Single Necasatorit

111

211 (

Day Ziua

Month Luna

Year Anul

311 312 313 314 315 316 317

Fee:

212

Number of entries S M

Keterangan:

Working place Locul de munca Office address Adresa de la serviciu Phone number Numar de telefon

Paraf

Tanggal Otorisasi

III. TRAVEL DOCUMENT INFORMATION / INFORMATII DESPRE DOCUMENTUL DE CALATORIE

Passport Number
Numarul pasaportului

Type of Passport Tipul Pasaportului

Place of Issue Locul eliberarii Date of issue / Data emiterii Day Month Ziua Luna

Ordinary Simplu/Turistic Service de Serviciu

Diplomatic Diplomatic Other (please specify) : . Altul (va rugam sa specificati)

Year Anul

Date of expiry / Data expirarii Day Month Ziua Luna

Year Anul

Name of persons traveling with the applicant and included in the Passport (fill if any) Numele persoanelor incluse in Pasaportul solicitantului care il/o insotesc in calatorie (daca este cazul)
No Relative (s) Grad de rudenie

Sex Sexul

Date of Birth (DD-MM-YY) Data nasterii (ZZ-LL-AAAA)

Name Numele

IV. SPONSOR IN INDONESIA (IF ANY) / SPONSOR DIN INDONEZIA

Type of sponsor Tip de sponsor Individual Individual Company Companie Government NGO International Institution Guvernamental ONG Institutia internationala Other (please specify) : Altele (va rugam sa specificati) ..

Name of person/institution Numele persoanei / instituiei

Address Adresa Phone number Numar de telefon

V.

OTHER INFORMATION / ALTE INFORMATII

Have you ever been to Indonesia before? Ati mai calatorit in Indonezia? Are you in possession of any other country's travel documents? Detineti documente de calatorie din alta tara ? Do you have a previous visa to enter Indonesia? Ati mai solicitat viza pentru Indonezia? Has your Visa application been refused before? Vi s-a respins vreodata cererea de viza? Have you ever been forced to leave Indonesia before? Vi s-a cerut vreodata sa parasiti Indonezia? Have you ever been convicted of a crime or an offence? Ati fost condamnat pentru delict sau infractiune? Return/Through Ticket/Airline Company Bilet dus-intors / Compania Aeriana Place of Issue (Travel Agent) Locul emiterii (Agentia de turism) Date of issue / Data emiterii Day Month Ziua Luna Yes Yes Yes Yes Yes Yes No No No No No No
If Yes, specify date and place Daca ati raspuns cu Da, specificati data si locul

Year Anul

Date of expiry / Data expirarii Day Month Ziua Luna

Year Anul

I declare that the information given above are true and that I intend to go to Indonesia only for the mentioned purpose and duration Declar ca informatiile de mai sus sunt adevarate si ca doresc sa calatoresc in Indonezia din motivele si pe durata mai sus mentionate

Applicants signature Semnatura solicitantului

Bucharest Bucuresti

DD - MM - YYYY ZZ - LL - AAAA

IMPORTANT NOTE / NOTA IMPORTANTA : To be completed in one set of application form with one photograph attached A se completa intr-un singur exemplar si a se anexa o fotografie Passport must be valid at least 6 (six) months to enter the Indonesian territory Valabilitate minima a pasaportului trebuie sa fie de cel putin 6 (sase) luni de la intrarea pe teritoriul indonezian Please allow at least 3 (three) working days for your visa to be processed Va rugam sa asteptati cel putin 3 (trei) zile lucratoare pentru procesarea vizei