THE EMBASSY OF THE REPUBLIC OF INDONESIA

BOSNIA AND HERZEGOVINA

Application No. ……..

The following items must be presented with this application form:

  1. Passports (valid for at least 6 (six) months) to apply Transit, Single Entry and 12 (twelve) months for Multiple Entry Visa, and 18 (eighteen) months for Limited Stay Visa.
  2. 1 (one) passport size photograph (taken not more than six months).
  3. Visa Fee*Transit(amount ……)

*Single Entry(amount ……)

*Multiple Entry(amount ……)

*Limited Stay (amount ……)*for 6 (six) months period

(amount ……)*for 1 (one) year period

(amount ……)*for 2 (two) years period

  1. Airline tickets/confirmed booking/letter from airline/travel agency, addressed to this office of travel INTO and OUT of Indonesia.
  2. Letter of Recommendation from reference/sponsor (if applicable)
  3. Copy of Approval Letter from Indonesia immigration office (if applicable)
  • Interview would be conducted prior to the approval of the Visa
  • Visa may be obtained by mail (submit completed application form with the required items and self-addressed envelope with sufficient postatge for registerd mail).

PERSONAL CHEQUES NOT ACCEPTED

  • TRANSIT

THIS Visa is good for single entry, non-extendable, inconvertible, and the maximum length of stay is up to 7 (seven) days. Visas are valid for entry within 90 (ninety) days from the date of issue.

  • SINGLE ENTRY

This Visa is good for single entry, non extendable, inconvertible and the maximum length of stay is up to 60 (sixty) days. Visas are valid for entry within 90 (ninety) days from the date of issue.

  • MULTIPLE ENTRY

This visa is good for multiple entry within 12 (twelve) months with each stay not exceeding 60 (sixty) days. Visas are valid for entry within 90 (ninety) days from the date of issue.

  • LIMITED STAY

This Visa is good for multiple entry within 12 (twelve) months. Visas are valid for entry within 90 (ninety) days from the date of issue

FOR OFFICIAL USE ONLY
TANGGAL DITERIMA:
BIAYA : / DISETUJUI
DITOLAK / INDEKS
KETERANGAN LAIN / NOMOR VISA
TANGGAL DIKELUARKAN
JANGKA WAKTU / :
:
:
CATATAN / PARAF

Application No.

Date / ______(DD-MM-YYYY) / Photograph
3 x 4
GENERAL
Length of Stay / ____ Day (s) / ____ Month / ____ Year (s)
Type of Visa / □Transit / □Single visa
□Multiple / □Limited stay
TRANSIT
Country of Destination / ______
Port of Departure / ______
Flight/vessel name / ______
VISIT
Purpose of visit / □Tourism / □Convention / □Family visit / □Sports
□Study / □Arts / □Commercial / □Others
Address in Indonesia / ______
City / ______
Province / ______
Phone number / ______
Flight/vessel name / ______
Port of entry into Indonesia / ______
Date of entry / ______(DD-MM-YYYY)
LIMITED STAY
Purpose of limited stay / □Work / □Joint family / □Social / □Others
Address in Indonesia / ______
City / ______
Province / ______
Phone number / ______
Port of entry into Indonesia / ______
Date of entry / ______(DD-MM-YYYY)
PERSONAL DATA
First name / ______
Middle name / ______
Family/surname / ______
Sex / □Male / □Female
Marital status / □Married / □Single
Place of birth / ______
Date of birth / ______(DD-MM-YYYY)
Nationality / ______
Address / ______
City / ______
Province/state / ______
Phone number / ______
Occupation/position / □Professional / □Government / □Sales
□Student / □Housewife / □Others
Name of company / ______
Address / ______
City / ______
Province/state / ______
Phone number / ______

PASSPORT INFORMATION

Passport/travel document number / ______
Place of issue / ______
Date of issue / ______(DD-MM-YYYY)
Date of Expire / ______(DD-MM-YYYY)
Type of passport* / □Ordinary / □Service / □Diplomatic / □Laissez-Passer

*Fill if type of passport is family

No / Relative / Sex / Date of birth (DD-MM-YYYY) / Name
□ / □ / □ / ______/ ______
□ / □ / □ / ______/ ______
□ / □ / □ / ______/ ______
□ / □ / □ / ______/ ______
□ / □ / □ / ______/ ______
□ / □ / □ / ______/ ______

Relative: 1=Husband, 2=Wife, 3=Child

Sex: F=Female, M=Male

SPONSORSHIP IN INDONESIA

Type of sponsor / □Individual / □Government / □International institution
□Company / □NGO / □Others
Name of company / ______
Address / ______
City / ______
Province/state / ______
Phone number / ______

MISCELLANEOUS

Have you ever been to Indonesia before? / □Yes / □No
Are you in possession of any other countries travel documents? / □Yes / □No
Do you have previous visa to enter Indonesia? / □Yes / □No
Have your visa application been denied before? / □Yes / □No
Have you ever been forced to leave Indonesia? / □Yes / □No
Have you ever been committed a crime or any offence? / □Yes / □No

I hereby declare that the statements given above are true and I understand that even if granted a visa, admission at the airport/port remains the discretion of the immigration authorities in Indonesia

Applicant’s signature

Place & date ______(DD-MM-YYYY)