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Please attach two head

& shoulder color photos

FOR OFFICIAL USE ONLY

appropriate to the size


of this blank (taken

last 6 months).

FOREIGN WORKER VISA APPLICATION FORM FOR ENTRY INTO


TAIWAN, REPUBLIC OF CHINA
The applicant must sign this form on the overleaf in person
Please complete all sections in BLOCK LETTERS
APPLICANT'S DATA OF APPROVED EMPLOYMENT:
1.
4.:
1032458179
Approval No.
Name of agency
2.
Approval authority

CLA

3.
Name of employer

5.
Name of physical
examination
hospital in home
country

PT.BIDAR PUTRA SUKSES


Klinik Hidayah Medical Centre

APPLICANTS'S DETAILS
Surname
6. ()
Full name (exactly as in passport)
Given

PUTRI NOVITASARI

7.()
Former or other name (if any)

8.()
Chinese name (if any)

9.
Nationality

INDONESIA, REPUBLIC OF()

10.()
Former or other nationality (if any)

11.
Sex

Male

12.
Marital Status Single Married Widowed Separated Divorced

13.
Date of birth
15.
ID No.

Female

Other

Year/Month/Day

1992/11/20
3510056011920002

14. (City)
Place of birth BANYUWANGI

(Country)
INDONESIA

16.

First time to work in Taiwan ?

17.
DS.WRINGINPUTIH RT.02/06 MUNCAR
Permanent address and telephone number in home country BANYUWANGI JAWA TIMUR

021-33177798

APPLICANTS'S PASSPORT
18.

Type
Regular
Other; Please specify
19.
Passport No.
21.
Date of Issue

AT274080
Year/Month/Day

2014/09/08

23.
Propose date of arrival

Year/Month/Day

2015/01/05

20.
Date of expiry
22.
Place of issue

Year/Month/Day

2019/09/08

KEDIRI

24.
Propose date of departure from Taiwan

Year/Month/Day

Taipei Economic and Trade Office in Indonesia

109639EDI3B1FQ32

ALL APPLICANTS ARE REQUIRED TO READ AND CHECK THE APPROPRIATE BOX FOR EACH
A.
Have you had any criminal record within or outside the territory of the R.O.C. or have you ever been denied
entry, ordered to leave or deported by the R.O.C. government ?
B.
Have you ever entered Taiwan, R.O.C. illegally ?

YES NO
YES NO

C.(),
Have you ever been afflicted with a communicable disease of public health significance such as AIDS, a
dangerous physical or mental disorder, or been a drug abuser or addict ?

YES NO

D.
Have you ever overstayed visitor or resident visas or worked illegally in Taiwan, R.O.C. ?

YES NO

E.()
Have you ever been a controlled substance (drug) trafficker ?

YES NO

F.
Have you ever been refused a visa an R.O.C. mission ?
G.
Have you ever applied for an R.O.C. visa with a different name ?
H.
Have you ever worked in Taiwan?

YES NO
YES NO
YES NO

Attention : YES answer does not necessarily signify ineligibility for a visa. If you answered YES to any of the questions
listed above or if you have any question in this regard, personal appearance at this office is recommended.

Acknowledgement :
I certify that:
1.
I have read and understood all the questions set forth in this application and the answers I have provided are true and correct to the
best of my knowledge.

2.
I understand that holding a Republic of China visa does not necessarily mean i will be allowed to enter the R.O.C.

3.
I understand that any false or misleading statement may result in the refusal of a visa or denial of entry into the R.O.C.

4.
I also understand that the government of the Republic of China reserves the right to withhold disclosure of the reasons for rejecting my
visa application, and to withhold fees deemed non-refundable.

5. ,
I understand that, once submitted, this application form will become the property of the government of the R.O.C. and will not be
returned to me.

6.

www.immigration.gov.tw
I am aware that R.O.C. citizens who have previously held household registration in Taiwan shall be subject to the laws of the Republic
of China while in its jurisdiction. According to Article 14 of the Regulations for Exit of Draftees, a draftee who has maintained household
registration in Taiwan and possesses dual citizenship shall enter into and depart from Taiwan by presenting his ROC passport. Any draftee
age male subject to conscription who enters Taiwan by presenting a foreign passport shall be restricted from departing from Taiwan.
Please visit the www.immigration.gov.tw for the conscription law.

WARNING :

Drug trafficking is punishable by death according to the criminal law of the Republic of China.
DATE OF APPLICATION

2014/12/05

APPLICANT'S SIGNATURE :
()

(Personal signature is required)

SIGNATURE OF THE APPLICANT'S AGENT :


Relationship to the

AGENT

Agent's full name, address and telephone


Name :
Address :

PT.BIDAR PUTRA SUKSES

Telephone No.

021-33177798

JL.CINYOSOG NO.88 RT.03/02 BURANGKENG SETU BEKASI JAWA BARAT

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