mpuszet waa (ex ar7eHAl) (aa / Paget) MSHA APPLICATION FOR VISA MMSE Atal 2rteiol ateetol Aalst AaiAlw Atalatolo} Bict > AAMAS SE Meo Ut Moe Be Ee Ieee 7ImAIolO} HUCh P AMAisIe wt ZiT | sled BAL atai7] iB > Tier NOSE GF, SAIN 7ImHtAI7] wHEHLICh ‘ion to til out this form > You must 1111 out this form completely and correctly, > You mst write in block letters either in English or Korean, > For multiple-choice questions, you must check [1] all that apply. If you select ‘Other’ , please provide us with more information in the given space. 1. el AHS / PERSONAL DETAILS 41.1 FBO 2S! QE ALO4/FUlL name in English (as show in your passport) Pu ola gare AA Family Nome (mame keluord@) BF Given Names (Kama depan + nena berngah ) (35m 45mm) 1 a _ nSamxtom) . SUGLANTO MARIA MAGDALEWA ge so aioe 1.2 SHO were 1.3 B Sex aea9e1 ergo! rin) HM /Malel ] O14 /Fonalel 1 (Wanita) alsin oo} ef ‘carted akon win a 1-4 HXABE Date of Birth (yim (Tg | nr¥.5 FAL Nationality Coen: Sean) sonata ewes (990 / 10/15 INDONESIA ae ee 4.6 BARE Country of Birth (ney0s Eolahramh. 7 B7HAESEE National Identity No, (ne ETP) or ote backround) ps WOO NESIA 51450050 35 200 3 1.8 Mol Sol SIRILS Ml cle Mets ALBH EA oF Have you ever used any other names to enter or depart Korea? OMS NIV] of Yost ] + Ol SEAL AMULS 2IM IT "Yes’ please provide details (2 Family None | Given Nae ) 1.9 SF BN OL Are you a citizon of mre then one camry? OSH YY ot vest J ol" AOL AL MULE 71M It “Yes! please write the countries. ( 2. ABBA WSUS / DETAILS OF VISA ISSUANCE CONFIRMATION * QMS SURMES SILOM BWR WEE Ale 710 (Section 2 is only for tose wo posass cnt rmation of visa issunce isasty the Imigraticn Otte of the Republic of Kora) 21 MBwBoaes is aa = ee ead a7 BAL 2.2 B22 Issue Date wee BA 2.3 OMY Passport No. 2.4 OFAN Paport Expiry Dato + ASHBIUMS WOVE Ale 128 (MeO olSslol Ae e AAA Mela — Tee Id Be) Those who have cont irmation of visa issuance aust move to section 12 (Declaration) to complete this trom (Those with visa issuance confirmation must not fill out section 3-11) 210m 257mm 12971 80) (78 BY)(42% / Page2) C1A3S / PASSPORT INFORMATION 3.1 ONE Passport Type S122 Diplomatic {| } 2 official (| e Regutar( /) viet other {1 “+ IEF BALES Ht “Other” please provide details ( ) 3.2 OLAS Passport Wo, Coo. patger)3.9 BR7t country of Passoort (negmap.4 WAM Place of swe (Lormpat cetak ) AQB4GE? \ndovera JARARTA BARAT 3.5 SBMA date of Issue (Ty! ceted]3.6 71ZICHEA! Date OF Eiry (rmasn berlate Pasper } ZOIDS 2B NS 3.7 CHE Of 31 CHF oo you have ay otter valid paseort 7 OZ MoT} ot Yes} =O I AL SALES 21M It Yes" please provide stalls 2) OFM Passport Type ‘S42 Diplomatic [ ] ‘BS Otticial [1 ‘Wet Regutar{ tet Other fT ) ofa Passport No ) 271 Oat of Paesort 4) 71202 Date Of Eiry 4. S&H / CONTACT INFORMATION, tc himan an ea 22 aE MN, Te Terettar 9 taman Chedus, Tarenng 4.1 8 A7X| Current Residential Address «8 A722} B= ELS} CHE AF 7IAL/ Write if it is different from the above adress: Tig tka meme tebsndary 1 alamat) 4.3 FCA Colt Prove No, (no HP) 4.4 YSIS Telaphane No, (M0. f4Pon 4.6 O10 E-mail CANBIBEG? OM S5>4195 mim - G05 yanoo. comm 4.6 MIRAI CIS) Eaorgency Contact Intormation Comer belepon darurat | yangticdale (hut perg, / 29 58 Ft ae in at Tayy 0) AER camty of resiame Thowwepn c) HB Teleshore to, 8) 24 Relationship to you 08 15 9907976 Cousin 5. BelAHst / MARITAL STATUS DETAILS. 5.1 SUM BOIALBE Current Marital Status Crmorndea ny ) 218 Married [ 4, Coeved) 18 Divorced { O18 Never married (1 ('beluim mein bogh) S25 RAY Boe B71 SHE 7H IK Mavi pln pride ite ot yar same. Antes paren ) a) Family Nome (in English) 1) & Given Mamas (in English) Supanto hal yn c) MBB Date of Birth (yyyy/mm/dd) @) SA National ity 1988 / 0b ho \nelowen 6} 24FEX) Residential Address 1) txt contact No, Hanon bec ste b64U 6. 8 / EDUCATION 6.1 A1B8H mat is the hiohest degree or level of education you have completed ? AAUSIA Masta’ sDoctoral Dopree | 1( 5.2. 153) 4B Bacholor's Dogroe { /J (51) 2B High Schoo! Diptona 1 ( prip2/>2) Jeb other [1 rum (me ) IER AN) AIS 71H IT “OU please provide details ( ) 6.2 88091 heme of Scr] HAMA SEDAN LeraYS sin ANA Location of Scot ty/province/cmntry) (Lo 0% Sekolah) Unuergtny bud, Aeon ny Pinon 10 210mm 237amt 84181 80p/w (8) |(0435 / Paved) 7. 4& / EMPLOYMENT 7.1 AQ! What ate your current personal circumstances ? A174 Entroprenour [J HIRI Self-Employed ( HE! Employed {| BPH Civil Sorvant {1 e148 Studont {1 SIAM Retired {| 2A Unemployed { 2iFt Other {2 + ‘IEF M8 Al AIS 1A It ‘Other’ please provide details ( ) 7.2. A AIA! Employment Details. a) S1A}/7/24/8t24 Nae of Company/ Insti tute/Schoot 'b) 91/2124 Your Positien/Course ©) SAV7IR/8 4 Address of Canpany/ Insti tute/Schoot 4) M8191 Tolephone No. 8. £4e1 BS / DETAILS OF SPONSOR 8.1 2821/8814 Do you have anyone soonsoring you for the visa ? OMS Not | of Yes J + “Ot et Al AIMEE 71M 11 Yes’ please provide details a) £821/SA/81402! Name of your visa sponsor (Korean, foreign resident in Korea, company, or instit ) b) HU H/AINE RUB Date of Birth/Business Registration No, ©) 2M Relationship to you 4) E Address ©} 210118 Phone No. 9. 2428 / DETAILS OF VISIT 9.1 SRR Purpose of Visit to Korea 23/82) Tourisn/Transit [| SAHRA /Meet ing, Conference {| 1B Medical Tourise ( } 17128 Business trip 1] A/S stugy/Iraining ALS woe | '291/21/39 Trade! Investment Intra- Corporate Transterce { ] 7M SE ERIGE_ Visiting Family’ BEO1e! Marriage Migrant {1 1/24 Diptonaic/Otticial [J let other (1 + IEF MA] SALAB 11 ‘Other’ please provide details ( ) 9.2 MROIR7|2+ intended Por iod of Stay 9.3 BRO Intended Date of Entry 9.4 MROLEX|(S%E EB) address in Korea including hotels) 9.5 83 G88 contact No. intorea 9.6 3171 Sz! SRB EEE! AA Have you travalted to Koren in the last 5 years 7 OMS HL] ob Yee (J ‘of" A A} AEM 21H 11 "Yes’ please provide details of any trips to Korea (8 tims, 2 ERRAL Purpose of Rant Visit ( » 9.7 8% Of DP} GAZ} OFEF tHe you traveled autside your cantry of vesidros, clung to Kora, in the last 5 yams ? OMS Hol} Of Yes {J} > ‘Ol’ SE Al SAU 71M If “Yos' please provide dotalls of these trips 32712) Poriod of Stay 3718 Name of Country (in English) BES Purpose of Visit Pere isla of Stay 210mm 257em( 2% 80a! (ARB |(443, / Pages) 9.8. SUR 7S FF 1M Ave you tr OMS Nol] Of Yost] + “Ol” AGH Al SEMIN 11 Yes’ plans provide details of the fanily mater. Yeu are traveling with rai ‘SWS Date of Birth =H 2494 FulK name in English ered fotiontity 2% Relations to you + BD: 7R9l wel - EA eS. ote: Dotinition of a Family Member’ your spouse. father, mother. children, brothers and sisters 10. 84224] / FUNDING DETAILS 10.1 SEAY|(O|F Sey 7}E) Estimated travel costs(in US dollars) 10.2 BYIAIEAI Who will pay tor your travel-related expenses ? (any person including yourselt and/or institute) a) M91/S/A}( CHE) 3 Nane of Person/Company( Insti lute) b) 228 Relationship to you c] “12148 Type of Support ) PE Contact fo, 11. ME 2H Al O14 / ASSISTANCE WITH THIS FORM. 11.1 0] ARAB AMOHECL CHE AlztS| SBS wRtSLI7 Did you receive assistance in completing this fora? ‘ol S894 A) ALALLIS If Yee" ploasa provide dotails of the person wo assisted you OMS WI 1 otvest 1 AMSG! Date of Binh 2A a a - 12) Ful Namo iat (234 Tolono No. e 12. M&F / DECLARATION + ABR AS aa ‘Those who possess confirmation of visa issuance must only complete section 1,2, and 12 of this fora Sele 0] AMA IME! H-SOl 712! Rol AMSA AMSIASS welch. Fst ele asIeIA IS Bele Fae Sow we AerBUCH. | declare that the statasents made in this application are true and correct to the best of my krowledge and bel ef 11 comply with the Immigration Act of the Republic of Korea, ‘and that | ‘NAGI (4. AL 21) DATE OF APPLICATION (yyyy /mm/cd) ir) Tania Tn tong fig vase sella eal fai Wal olgiiol AF FE Ze WAR Ae Signature of Parent or Lagal Guardian's for a person under 17 years of ape ae auu vitomar 1 RRRRCIL ARAL, ATOMS (WE 5] AWC AEA 1mm 237mm 4) (4B)