: 15.025,684.0-215,000
NAMA : DIANA MARTHINA CHALIM
ALAMAT: BEVERLY AVENUE BA NO. 16.
‘ TERDAFTAR
RT.001 RW.028 BELIAN 4
BATAM KOTA
BATAMREPUBLIK INDONESIA
KANTOR WILAYAH KEP. RIAU
NIM KELAS I KHUSUS TPI BATAM.
IGKU PUTRI NO. 3 BATAM CENTRE
KEMENTERIAN HUKUM DAN HAK ASASI MANUSIA A;
IZIN TINGGAL TERBATAS ELEKTRONIK
ELECTRONIC LIMITED STAY PERMIT
NIORA + BKL6UAMINO648,
Permit Number 2C21BK0309-X,
‘Stay/Muliple Entries Permit Expiry 01.03.2024
Stay Permit Index mB
Fall Name : DAGFINN HATLESKOG
Place / Date of Birth; FIOTLAND / 28-08-1951
Passport Number: 33078274
Passport Expiry
Nationality
Gender
Address PERUMAHAN BEVERLY BLOK AVENUE NO.16
‘Occupation : OTHERS
Status FAMILY UNION
Guarantor Name : DIANA MARTHINA CHALIM
DISCLAIMER :
1, According to Article 7L Act Number 6 Year 2011 concerning Immigration, every ehinges af civil status, citizenship, ceeupation,
Guarantor, or change of address must he reported to Local Lmmigration Office in i immediate period af tise.
‘This Limited Stay Permit (online) must be attach to the bearer’ Passport a all times
For further infarmation please do not hesitate to contact Local Immigration Otfice or do visit our website wow, nisras god
‘This Electronic Limited Stay Permit is generated automatically by the Lmmigration Infarmation Management System
‘Batam, 14402-2023
‘Head of Kelas 1 Khusus TPE Batam Immigration Office,PASSPORT
:
é
PASS NORGE NOREG NORWAY
PASSPORT ‘Type peeoter Passnr./Passport No.
P SsohSae NOR 33078276
rl
Etiemavi-Etemama/Sumar
HATLESKOG
Fomam-ForenamniGiven name
DAGFINN
NasjonalilevNatonalty Hoyde-HogdHeignt
NORSK NORWEGIAN 182 CM
FodaledtatiDate of bit 108 Fedssisnr/Personal No.
28 AUG 54 “= 280851 47309
Myodiahet MyndigheitiAuihorly,
KGL. NORSK ANBASSADE SINGAPORE
‘Utsied! den-Uisirtve deniiate of issue UnderskritHolder's signature
a ek Dagf Sfetinteng
O05 APR 28
PVNORHAT LESKOG<