consulate general of the republic of indonesia Melbourne Australia 72 Queens Road Melbourne Victoria 3004 T 03 9525 2755 F 03 9525 1588 www.kjri-melbourne.org recent colour photo 3.5 x 4.5 cm do not staple journalistic visa application V 03 Fill in with ink and use block letters. attach 3 (three) passport size photographs. Personal Details Full name Place/Date of birth Nationality Present occupation Residential address Company/media Address of company Type of media Newspaper Radio Television Other Previous publications (books/papers/etc) Proposed subjects of study/observation/ coverage in Indonesia Duration of stay Day(s) Month(s) Year(s) Port of entry Present status (if any) in other organisation/ club/sports/political/etc curriculum vitae Education and training Professional and career Signature Melbourne Page 1 of 6
DEPARTEMEN LUAR NEGERI REPUBLIK INDONESIA DEPARTMENT OF FOREIGN AFFAIRS OF THE REPUBLIC OF INDONESIA APPLICATION FOR FILM/VIDEO SHOOTING PERMIT (PERMOHONAN IZIN UNTUK SHOOTING FILM/video) Applicant s full name pemohon Place/Date of birth Tempat/tanggal lahir Nationality Kebangsaan Residential address Alamat pemohon City Kota Telephone Telepon Name of company Nama perusahaan Address of company Alamat perusahaan State/Postcode Kodepos Mobile handphone City Kota Telephone Telepon Purpose of production Tujuan produksi State/Postcode Kodepos Facsimile Facsimile Previous film/video shooting experience in Indonesia Pengalaman shooting film/ video di Indonesia sebelumnya curriculum vitae Education and training Latar belakang pendidikan dan pelatihan Professional and career Latar belakang profesional dan karir Signature Melbourne Page 2 of 6
crew (kerabat kerja) 1. Full name 2. Full name 3. Full name 4. Full name 5. Full name 6. Full name 7. Full name 8. Full name Page 3 of 6
DEPARTEMEN LUAR NEGERI REPUBLIK INDONESIA DEPARTMENT OF FOREIGN AFFAIRS OF THE REPUBLIC OF INDONESIA Statement To complete our application for photography, film/video shooting permit, we hereby declare that: 1. We shall obey all the rules and regulations issued by the Government of the Republic of Indonesia, whether they are the ones issued by the Central Government or by the Local Government. 2. We are aware of the obligation to report, upon arrival, to the Department of Foreign Affairs cq the Directorate of Foreign Affairs Information for a general briefing on film/video shooting procedures in Indonesia. 3. We shall not make any shooting or recording of any object/location other than what are indicated in the shooting permit based on the script/synopsis forwarded by us. 4. We shall neither make any shooting/recording of prohibited objects and restricted locations nor of any other objects/locations which might create a harmful impression to the image of the government and the nation. 5. We shall be responsible and pay full compensation for the expense that might be occurring from filming/recording prohibited objects and restricted areas. 6. We agree to bear all the expenses of a Department s official appointed to accompany the team during filming/recording, i.e. board and lodging, transportation cost, daily allowance and any other additional expenses that might occur during filming/recording. 7. We are to re-export all equipment after completion of our activities; 8. We are to submit one release copy of the film/video to the Department of Foreign Affairs cq Directorate of Foreign Affairs Information through the Indonesian Embassy, and we have no objection whatsoever to its being used by the Indonesian government for non-commercial purposes based on national interest in Indonesia as well as abroad. Signature Melbourne Page 4 of 6
details of visit to indonesia No Date location Subject/Activity Page 5 of 6
details of equipment Item no Description of equipment No Weight Value (US$) Country of Origin Page 6 of 6