Indonesia Visa Application Form Page 4
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1
2
3
4Have you ever been forced to leave Indonesia?
:
Yes
No
Have you ever been committed a crime or any offence?
:
Yes
No
Return/Through ticket/Airline Company:
Place of Issue
:
–
–
Date of Issue
:
(DD-MM-YYYY)
–
–
Date of Expire
:
(DD-MM-YYYY)
I hereby declare that the statements given above are true and I understand that even if granted a visa,
Admission at the arirport remains the discretion of the Immigration authorities in Indonesia.
Applicant’s Signature
–
–
………………
(DD-MM-YYYY)
*To be Complete in duplicate with two photographs attached.
*Passport must be valid at least six months.
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