KEDUTAAN BESAR REPUBLIK INDONESIA

EMBASSY OF THE REPUBLIC OF INDONESIA

Elfenauweg 51 - 3006 Bern
Tel (031) 3520983/84/85
Fax (031) 3516765
VISA APPLICATION FORM
Please PRINT and use DARK INK
It is important that all items are to be filled in. Visa application will not be processed unless all required items are filled in.

VISA REQUESTED PHOTO OFFICE USE ONLY

The validity of visa starts from first day of arrival. Date of receipt (day/month/year)
The 90 days limit is mentioned in the visa as date
of expiry. If the visa is not used to enter Indonesia
within 90 days after the date of issuance, it will be
void to use.
Single-entry Visa number
Valid only for single-entry visit. Attach recent photograph here
Maximum stay of 60 days. size 3,5 x 4,5 cm
Multiple-entry
Can be used for multiple entries. Valid to Visa type and index
use for 1 year. Maximum stay of 60 days
for each visit.
Temporary-stay
For max stay of 2 years in Indonesia.
Special visa authorization needed.
Payment
Diplomatic & Service
For diplomatic and service passports
only.

A. APPLICANT
Surname (as in passport) Given name (as in passport) Sex
Male Female

Place of birth (city and country) Date of birth (day/month/year) Marital status
Married Single Other

Nationality Passport number Type of passport

Ordinary Service Diplomatic Laissez- Other
Passer Travel
Document
Passport issuing authority Date of issue of passport (day/month/year) Valid until (day/month/year)

B. CONTACT INFORMATION
Applicant's address (street name and number) Phone

Postal code City Mobile

E-mail address Fax

C. PROFESSION/OCCUPATION
Name of company/institution/school to which applicant belongs Post/rank/position held at present

(For retirees only) Name of company/institution/organization to which applicant belongs (For retirees only) Principal former position

Company/institution/school address (street name and number) Phone

Postal code City Fax

Page 1 of 2
Consular Section - Embassy of Indonesia - Bern
KEDUTAAN BESAR REPUBLIK INDONESIA
EMBASSY OF THE REPUBLIC OF INDONESIA
Elfenauweg 51 - 3006 Bern
Tel (031) 3520983/84/85
Fax (031) 3516765

D. COMING TO INDONESIA
Purpose of visit to Indonesia (please select according to the nature of your visit)
Tourism Sports Non-profit activity
Family visit Press and media Internship
Study Commercial/business Conference
Culture visit Social visit Others (please specify)
Stay in Indonesia
Port of entry Date of entry (day/month/year) Intended length of stay in Indonesia

Name of ship or airline/flight number Intended places to visit in Indonesia

Address of hotel/name and address of person with whom applicant intends to stay at Phone

Do you have an invitation/reference? Contact/sponsor's name Contact/sponsor's company/organization/institution

Yes (if yes, please attach)
No No
Contact/sponsor's address Phone Fax

Is any of the following applicable to you?

1. Are you in possession of other country's legal and valid visa? Yes No
2. Have you ever been granted Indonesian visa? Yes No (if yes, please specify the year) ->
3. Has your application for Indonesian visa ever been denied? Yes No
4. Have you ever been ordered to leave Indonesia? Yes No
5. Have you ever been arrested or convicted of a criminal act? Yes No

E. CHECKLIST (for official use only - do not fill In this part)

Please use this checklist to lodge a visa application (please tick the box for each submitted item)
1. Original passport
2. Completed visa application form with photo attached
3. Copy of flight reservation or flight ticket
4. Copy of valid residence permit (for non-Swiss national only)
5. Stamped return envelope for registered mail (if passport to be sent back by post)
6. Visa payment
Single-entry visa : CHF 60
Multiple-entry visa : CHF 125
Temporary-stay visa up to 6 months : CHF 65
Temporary-stay visa up to 12 months : CHF 125
Temporary-stay visa up to 24 months : CHF 220
7. Method of payment
Bank transfer
( UBS 3001 Bern - IBAN CH55 0023 5235 9203 3702 Q - Embassy of Indonesia 3006 Bern)
Additional item for temporary-stay visa application only
8. Copy of visa authorization letter issued by Indonesian Immigration Office

I hereby declare that the statements given above are correct and complete to the best of my knowledge.

I understand that even if granted a visa, admission at the airport remains the discretion of the Immigration authorities in Indonesia.

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

Place and date Signature

Page 2 of 2
Consular Section - Embassy of Indonesia - Bern