印尼签证表

SANLITUN

DIPLOMATIC OFFICE BUILDING B BEIJING 100600

Tel. No. 65325486-88

Fax No.65325368, 65326279

Day 日

Month 月

Year 年

Number 号码

Date 日期

Tel .电话

Sex 性别

6.Tel.电话

I HEREBY DECLARE THAT:我谨此申明:

Beijing,

1. THE STATEMENTS GIVEN ABOVE ARE TRUE AND CORRECT 上述各项均属实情

2. I REALIZE THAT EVEN THOUGH POSSESING A VALID VISA TO INDONESIA, PERMISSION FOR ENTRY REMAINS AT THE DISCRETION OF THE IMMIGRATION AUTHORITIES IN INDONESIA

我虽然获得印尼入境签证,但登陆或入境之许可权仍由印尼移民局定夺.

Signature:

签名:

I AM ALSO AWARE :我亦确知:

1. THAT DURING MY VISIT IN INDONESIA I HAVE TO REFRAIN FROM: 当我在印尼逗留期间,我必须防止下列事项:

a. Being engaged in any occupation or institution paid or unpaid 不得在任何公司或机构任职,不管受薪或不受薪

b. Over Staying 不得逾期居留

2. THAT IF I FAIL TO COMPLY WITH THE ABOVE MENTIONED REQUIREMENT, I AM LIABLE TO PROSECUTION AND EXPULSION. 如我违反上述保证,我将被控之于法及被驱逐出印尼.

032002

DATE OF ENTRY

ITINERARY IN INDONESIA

PORT OF ENTRY Tel.电话

到印尼的目的

姓名

出生地点及日期

入境日期

在印尼旅行地点

VISA APPLICATION FORM FOR VISIT-SINGLE / SEVERAL JOURNEY (S)

号码

FAMILY MEMBERS ACCOMPANYING AND INCLUDED IN PASSPORT OF APPLICANT 在申请者护照内伴随之家属

Relationship with Applicant

关系

护照在入境签证后须仍有最少六个月之有效期

住宅或暂时地址

PASSPORT / TRAVEL DOCUMENT 护照或旅游证件

PROFESSION / OCCUPATION, NAME & ADDRESS OF FIRM OR COMPANY

职业/职位,公司名称及地址Male 男性Female 女性

NATIONALITY 国籍

HOME OR TEMPORARY ADDRESS

Valid Until 有效期

PASSPORT MUST BE VALID FOR AT LEAST ANOTHER 6 MONTHS AFTER DATE VISA ISSUED

Type 种类

Place of Issue 签发地点

NAME IN FULL (IN CAPITALS) 申请者姓名(请用大写拼音字母填写)CHINESE CHARACTER AND CODE NUMBER

姓名(用中文填写)及密码

Sex 性别

PLACE & DATE OF BIRTH 出生地点及日期

Place & Country 何国何地

PURPOSE OF JOURNEY TO INDONESIA

Name & address reference in Indonesia 印尼担保人或公司的具体名称和地址

SPONSOR IN INDONESIA 在印尼之担保人

Number Name in Full

Place & date of Birth THE EMBASSY OF THE REPUBLIC OF INDONESIA

B E I J I N G

短期签证申请表(一次或多次)

拟由何处入境

LENGTH OF INTENDED STAY

停留天数

Given names 名

Surname 姓