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: 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 BATAM REPUBLIK 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<

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