Formulir Isian Lapor Diri A
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KEDUTAAN BESAR R.I. PRAHA
FORMULIR LAPOR DIRI Reg No. :..........................
1. 2. 3. 4. 5. 6. 7. 8.
9.
10. 11. 12. 13. 14. 15. 16. 17.
Nama Lengkap Tempat & Tgl. Lahir Jenis & Nomor Pasport Nomor Registrasi Dikeluarkan oleh Tanggal Dikeluarkan Masa Berlaku Sampai Alamat di Indonesia a. Kantor
: : : : : : : : :
.......................................................................................................................L/P ..................................................................................,........./........./................... ..............................,............................................................................................. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ b. Rumah : ............................................................................................................................ ............................................................................................................................ Keluarga terdekat yg dapat dihubungi di Indonesia : Nama : ............................................................................................................................ Alamat : ............................................................................................................................ ............................................................................................................................ Tanggal Tiba di Ceko : ............................................................................................................................. Maksud Datang ke Ceko : ............................................................................................................................. Rencana Lama Tinggal : ............................................................................................................................. Nama Sponsor di Ceko : ............................................................................................................................. Alamat Sponsor di Ceko : ............................................................................................................................. ............................................................................................................................. Alamat selama di Ceko : ............................................................................................................................. ............................................................................................................................. Telp/Mobile di Ceko : ............................................................................................................................. Alamat E-Mail : .............................................................................................................................
Praha,.........................,.............. Pelapor,
Pas Foto F
(
* Catatan :
Mohon setiap Perubahan alamat / Kepindahan / Kepulangan ke Indonesia agar diberitahukan kepada KBRI Praha di No Faks : + 420- 257 212 105 E-mail : [email protected]
)
FORMULIR LAPOR DIRI Reg No. :..........................
1. 2. 3. 4. 5. 6. 7. 8.
9.
10. 11. 12. 13. 14. 15. 16. 17.
Nama Lengkap Tempat & Tgl. Lahir Jenis & Nomor Pasport Nomor Registrasi Dikeluarkan oleh Tanggal Dikeluarkan Masa Berlaku Sampai Alamat di Indonesia a. Kantor
: : : : : : : : :
.......................................................................................................................L/P ..................................................................................,........./........./................... ..............................,............................................................................................. ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ b. Rumah : ............................................................................................................................ ............................................................................................................................ Keluarga terdekat yg dapat dihubungi di Indonesia : Nama : ............................................................................................................................ Alamat : ............................................................................................................................ ............................................................................................................................ Tanggal Tiba di Ceko : ............................................................................................................................. Maksud Datang ke Ceko : ............................................................................................................................. Rencana Lama Tinggal : ............................................................................................................................. Nama Sponsor di Ceko : ............................................................................................................................. Alamat Sponsor di Ceko : ............................................................................................................................. ............................................................................................................................. Alamat selama di Ceko : ............................................................................................................................. ............................................................................................................................. Telp/Mobile di Ceko : ............................................................................................................................. Alamat E-Mail : .............................................................................................................................
Praha,.........................,.............. Pelapor,
Pas Foto F
(
* Catatan :
Mohon setiap Perubahan alamat / Kepindahan / Kepulangan ke Indonesia agar diberitahukan kepada KBRI Praha di No Faks : + 420- 257 212 105 E-mail : [email protected]
)
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