Request for Exit-Re-entry Permit
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Dit. Jend. Imigrasi
di Jakarta (or other city where you work/reside)
Hal: Permohonan Izin Masuk Kembali Beberapa Kali
Yang bertanda tangan di bawah ini : (this is the sponsor's info)
Kami mohon dapatlah kiranya diberikan Izin Masuk Kembali Beberapa Kali atas nama (pegawai/istri - put in the appropriate relationship) kami, yakni:
Nama : Name (of person you want to get the exit/re-entry permit for)
Kebangsaan : Nationality
No. Paspor : Passport Number
Untuk jangka waktu: period of time requested (can request 6, 12, 24 months)
Permohonan ini kami ajukan sehubungan dengan yang bersangkutan akan mengadakan perjalanan keluar negeri dalam rangka kunjungan keluarga.
Demikian permohonan kami, atas bantuan dan kesediaan Bapak, kami mengucapkan banyak terima kasih.
Typed out name
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