‫انجًهـىسَح انجضائشَـــــــح انذًَقشاغُح انشـــــعثُح‬

……………………………. ‫انًشكض‬ PEOPLE’S DEMOCRATIC REPUBLIC OF ALGERIA

Post : JAKARTA
‫غـــهـــــــة تــأشــــــــــــُشج‬ ‫َىع انتأشُشج‬
Visa type

VISA APPLICATION
‫انهقة‬ ‫االسى‬ ‫انصىسج‬
Family Name First Name
‫اسى آخش‬ ‫اإلسى قثم انضواج‬ Photo
Maiden Name Other Name
‫تاسَخ و يكاٌ انًُالد‬ ٍ‫ف‬ ‫انثهذ‬ 3X4
Date and Place of Birth / / tA Country
ٍ‫ات‬ ٍ‫و ات‬
Father’s Name Mother’s Name
‫انحانح انعائهُح‬ ‫أعضب‬ )‫يتضوج (ج‬ )‫يطم (ج‬ )‫أسيم (ج‬
Marital Status Single deirraM decroviD wodiw)re(

‫انجُسُح انحانُح‬ ‫انجُسُح األصهُح‬

ytilanoitaN tneserP Nationality of Birth
ٍ‫انعُىاٌ انشخص‬ ‫انجُس‬ ‫ركش‬ ً‫أَث‬ ‫خاص تاإلداسج‬
Personal Address Gender Male Female For Office Use Only
Tel :
Husband –Wife
‫انهقة‬ ‫اإلسى‬
Family Name First Name
‫تاسَخ و يكاٌ انًُالد‬ ‫نثهذ‬ ‫جُسُح‬ ‫سقى انطهة‬
Date and Place of Birth / / Country Nationality Application Number

Children -‫األغفال‬ To be filled only if the child is on your passport and traveling with you-‫ال ًَهً إال فٍ حانح سفش األوالد‬ ‫تاسَخ اإلَذاع‬
‫االسى و انهقة‬ ‫تاسَخ انًُالد‬ ‫يكاٌ انًُالد‬ ‫نجُسُح‬ Received on
Family Name-First Name Date of Birth Place of Birth Nationality

‫عذد يشاخ انذخىل انًشخصح‬

Number of Authorized entries
Type of travel document ‫غثُعح وثُقح انسفش‬
‫جىاص سفش عاادي‬ ‫وثُقح أخشي‬ )‫(تىظُح‬
Ordinary Passport Other Document ( give precision) ‫يذج اإلقايح‬
Duration of Stay

Passport Number-‫سقى‬ Issued on Authority-‫انصادس‬ / / Expire On- ٍ‫َُتهٍ ف‬

(*) ‫تأشُشج يطهىتح نهذخىل‬ ‫يشج واحذج‬ ٍُ‫يشت‬ ‫عذج يشاخ‬ ‫انعشَثح انًستحقح‬
Visa Solicited For (*) 1 entry 2 entries Multiple entries xaT

‫انًهُح‬ ‫انًستخذو‬ ‫سقى انتأشُشج‬

Occupation Employer № Visa
ٍُ‫انعُىاٌ انًه‬ Tel
Company Address
‫فٍ حانح عثىس‬ ‫انىجهح انُهائُح‬ ‫صالحُح انتأشُشج‬
In Case Of Transit What’s Final Destination Validity Of Visa
(*) ‫هم نذَكى تأشُشج دخىل نهزا انثهذ‬ ‫َعى‬ ‫ل‬ ٍ‫ي‬
Do You Have A Visa For This Country(*) Yes oN From…………….
ً‫إن‬
At………………..
‫انعُىاٌ أثُاء اإلقايح‬ ‫غشض اإلقايح‬
Address During Your Stay Purpose Of Stay ‫سئُس انًشكض‬
‫يذج اإلقايح‬ ‫ َىو‬30 ‫ َىو‬90 ‫آخش‬ ‫تاسَخ انذخىل‬ )‫(اإليعاء و انختى‬
Length Of Stay 30 Days 90 Days Others Date Of Entry ……/.… /… Head of the post
(Signature and Stamp)
‫هم سثق نكى اإلقايح تانجضائش‬ ‫َعى‬ ‫ال‬ ‫يذج اإلقايح‬
Have you been already to Algeria Yes No Length Of Stay
‫كى‬ ‫فٍ أٌ تاسَخ‬ ‫عُىاٌ اإلقايح‬
How Many Times When Address
‫انتضو تًغادسج اإلقهُى تعذ اَقعاء أجم الانتأشُشج انتٍ ستًُح نٍ و تعذو قثىل أٌ عًم يأجىس أو غُش يأجىس خالل إقايتٍ و تعذو اإلقايح تصفح َهائُح‬
I undertake to leave the Algeria territory at the expiration of the visa, and to refuse any employment being paid or not, during my
stay and do not establish there
‫ فٍ حانح خطأ أو عذو يمء تعط انخاَاخ أٌ َشد عٍ غهثكى‬،‫ تًهً جًُع انخاَاخ تحشوف واظحح‬: ‫هاو‬
IMPORTANT All categories must be completed in Capital Letters in case of mistake or omission your demand will be
rejected
(*) Put the Cross in the category corresponding to your answer- ‫فٍ انجىاب انًختاس‬ ‫ظع عاليح‬

)‫انتاسَخ و إيعاء انًعٍُ (صاحة انطهة‬

DATE and APPLICANT’S SIGNATURE