EMBASSY

OF THE REPUBLIC OF INDONESIA
BUENOS AIRES, ARGENTINA / / Mariscal Ramon Castilla 2901
Buenos Aires
Phone : (11) 4807-2211
Fax No.: (11)4802-4448
VISA APPLICATION FORM FOR SINGLE VISIT OR MULTIPLE ENTRY
1. / Full Name of Applicant / : / Male / Female
------
Place and date of birth / : / ------
2. / Nationality / : / ------
Passport Number / Travel Documents / : / ------
Place and date of issuance / : / ------
Valid Until / : / ------
3. / Entry Permit / Visa to another country / : / ------
Number / : / ------
Place and date of issue / : / ------
Expiration date / : / ------
4. / Name (s) of family members included in applicant's passport who are applying for visa.
[ Full name, family relationship, sex and date of birth.]
N a m e / Family Relationship / Date of birth / Male/Female
a.
b.
c.
5. / Occupation/position / : / ------
Name of Firm of employment / : / ------
Address / : / ------
Postal Code : Phone :
Home address / : / ------
Postal Code : Phone :
Name of reference in Indonesia / : / ------
Address of reference / : / ------
Do you have a letter of invitation / : / (please attach copy)
------
6. / Purpose of visit to Indonesia :
(Please circle one according to the nature of your visit).
Governmental Visit / Business Visit / Social or Cultural Visit
  1. Government of Argentina - Government of Indonesia
  2. International Organization - Government of Indonesia
  3. Private SectorGovernment of Indonesia.
  4. Individuals - Government of Indonesia
/
  1. Industrial
  2. Commercial
  3. Agriculture
  4. Transport and Communication
  5. Public Works andPublic Utilities
  6. Religious
  7. Press andPublic Communication
  8. Promotion Visit
/
  1. Social
  2. Health and Medical
  3. Educational
  4. A r t s
  5. Sports
  6. Family Visit
  7. Tourism
  8. Study
  9. O t h e r s

Type of Visa Requested :
(Please circle accordingly)
01. Single Entry Visa / 02. Multiple Entry Visa / 03. Transit Visa
Length of intended stay in Indonesia / : / ------
Port and date of Entry / : / ------
Place to be visited in Indonesia / : / ------
Previous visa for Indonesia granted to the applicant / : / ------
Type / : / ------
Number / : / ------
Place and date of issue / : / ------
Place and date of previous entry to Indonesia / : / ------
7. / Has your application for Indonesian Visa ever been denied / : / ------
Have you ever been ordered to leave Indonesia / : / ------
Have you ever been arrested or convicted / : / ------
8. / Other information which will be useful in considering this application:
a. / Are you in possession of other country’s legal and valid Immigration documents / : / ------
b. / Number of return / through ticket / : / ------
Airline Company / : / ------
Place and date of issue / : / ------
Expiration date / : / ------
I hereby to declare that:
1. All the statements I have given above are true and correct
2. I am fully aware even though I possess a valid visa to enter Indonesia,entering the Indonesian territory will remain at the discretion of the Immigration Authorities at the port of entry.
I am also aware that:
1. During my visit to Indonesia I will refrain from:
  1. Engaging in any occupation in any institution - either beingpaid or unpaid
  2. Staying beyond the duration of Visa

2. Failing to comply with the above requirements, I will be liable to prosecution or expulsion.

Completed at: ______Date: ______

(PHOTOGRAPH)
3 BY 4 cm / Signature of Applicant
(Same as in passport)
______
Full name printed: ______
FOR OFFICIAL USE ONLY / SP. NO.:
1. / Telah diberikan visa atas kuasa sendiri
Macam Visa / :
Nomor Visa / :
Lamanya diizinkan tinggal di Indonesia / :
Tanggal pemberian visa / :
2. / Ijin Dirjenim no. / :
Buenos Aires,