EMBASSY OF THE REPUBLIC OF INDONESIA 55 PARKDALE AVENUE, OTTAWA, ON K1Y 1E5

VISA APPLICATION FORM

This form is completed on your computer or in CAPITAL LETTERS

TYPE OF VISA REQUESTED

1 (one) Photo

Single‐entry Can only be used for one entry, valid for 90 days after the date of issuance with a maximum stay of 60 days 

staple or glue the photo here 

Multiple‐entry Can be used for multiple entry  within 1 year with a  Maximum stay of 60 days per visit Limited Stay  Needs authorization letter from Directorate General of Immigration in Jakarta, Indonesia 

Diplomatic and Special / Service Passport Single entry with a maximum stay of 30 days 

1 Applicant’s Full Name as mentioned in your passport

Family Name:  Given Names:   Gender:         Male                 Female 

Place of Birth (City‐Country):  Date of Birth (DD/MM/YYYY):  Marital status : 

  Married     Single     Other:  

Nationality:  Passport Number:  Type of Passport:  

       Ordinary                Diplomatic / UNPL                                            Special/service 

Passport Place of Issuance:  Passport Date of Issue (DD/MM/YYYY):  Passport Date of Expire (DD/MM/YYYY): 

2 Applicant’s home address in Canada

Number and name of Street  Apt. / Unit No.  Home Phone: Area code / Number 

City   Province  Postal Code  Mobile:   Area code / Number 

Email address :  

3 Full Time Occupation / Student

Name of Company / Educational Institution;  

 Position:  

Number and name of Street :  Work  Phone:   Area code / Number 

City   Province  Postal Code  Mobile:   Area code / Number 

4 Purpose of Travel

  Tourism      Family Visit    Study    Internship    Press & Media  

  Film Making    Arts    Sports     Workshop    Seminar 

  Conference    Business/Commercial    Industry    Mining    Agriculture 

  Official Visit/Meeting    Diplomatic Posting     Others: 

5 Length of stay and Flight / Cruise Ship information to and from Indonesia

Length of Stay (days)  Date of Entry  City and Port of Entry  City and Port of Exit 

Date of Exit  Flight / Cruise Ship Number  Flight / Cruise Ship Number 

6 Hotel Name and Address in Indonesia (first arrival)

Hotel Name:  Hotel Address : 

City & Province:  Phone Number: 

7 Indonesian Sponsor (not applicable to Tourism)

Name of Sponsor  Sponsor’s Title/Position  Work  Phone:   Area code / Number 

Name of Company / Institute   Fax Number : Area code / Number 

City / Province  Postal Code  Mobile (if any) : Area code / Number 

8.  Are you in Possession of other Country’s Valid Passport      Yes        No 

If Yes,  Specify the Country:  

9 Does any of the following apply to you Yes No Please Specify:

a  Have you ever travelled to Indonesia       

b Has your visa application for Indonesia ever been denied  

     

c  Have you ever been ordered to leave Indonesia       

d Have you ever been arrested or convicted of a criminal act?  

     

1. I hereby declare that the statement given above is true and correct to the best of my knowledge.

2. I understand that possession of a Visa does not automatically entitle the bearer to enter Indonesia upon arrival if he or she is found inadmissible.

3. I understand that any false or misleading statement may result in permanent refusal of a visa or denial of entry into Indonesia.

4. I am also aware that failing to comply with the above requirements, I will be liable to prosecution or expulsion.

Applicant’s Signature and Date       

  

                               Date :