EMBASSY OF THE REPUBLIC OF INDONESIA OSLO - NORWAY

Visiting address: Fritznersgata 12, 0264 Oslo Postal address: PO Box 4057 AMB, 0244 Oslo

Tel. (47) 22 12 51 30 Fax. (47) 22 12 51 31 Website: www.indonesia-oslo.no

E-mail: kbrioslo@online.no

I. GENERAL

Length of Stay in Indonesia Day(s) Month(s) Year(s)

Date of Entry

Port of Entry into Indonesia

Type of Visa

Country of Destination

Port of Departure

Flight No / Vessel Name

Type of VisaFamily VisitTourism

Study CommercialSportsConvention

Arts Others

Place of Visit

Flight No. / Vessel Name

C. FOR LIMITED STAY PURPOSE

Purpose of Limited Stay

Address in Indonesia

ProvinceCity

Phone / Mobile No.

First Name

Last Name

Sex / Marital Status Male Female UnmarriedMarried

Nationality

Place of Birth

Address

Post Code / City Country

Phone / Mobile Number E-mail

II. PERSONAL DATA

Photograph

Limited Stay ( go to "C" )Single Visit ( go to "B" )Transit (go to "A")

Multiple Visit (go to "B")

Date of Birth - - dd-mm-yyyy

B. FOR VISIT PURPOSE

A. FOR TRANSIT PURPOSE

*PLEASE FILL OUT THIS FORM ELECTRONICALLY BEFORE PRINTING.

Name of Company

Occupation / Position Government SalesStudentHousewife OthersProfessional

Address(Tourist may not fill this part)

City Country

Phone Number Mobile No.

III. PASSPORT INFORMATION

Passport / Travel Document No.

Place of Issue (city)

Date of Issue Expiry

Type of PassportIV. SPONSORSHIP IN INDONESIA

Type of Sponsor

CompanyGovernment

NGOReg. / Intl. Organization

OthersIndividual

Name of Company

Address

City Province

Phone / Mobile No. E-mail

V. MISCELLANEOUSHave you ever been to Indonesia before ? Yes NoDo you have a previous visa to enter Indonesia ?Has your Visa application been rejected before ?Have you ever been forced to leave Indonesia before ?Have you ever been convicted of a crime or an offence ?

Yes NoYes NoYes NoYes No

Flight Name & No.

I hereby declare that the statements given above are true and I understand that if granted a visa, admission at the airport remains at the discretion of the Immigration authorities in Indonesia.

Signature Date of Today

* To be completed with 1 (one) photograph attached. * Passport must be valid at least 6 (six) months

FOR OFFICIAL USE ONLY Telah diberikan Visa atas kuasa sendiri : Macam Visa : ...................................................................................... Nomor Visa : ...................................................................................... Lama diijinkan tinggal : ...................................................................................... Oslo, ......................................................................

Ordinary Diplomatic Service