VISA APPLICATION FORM TO ENTER JAPAN

(Paste photo here)

45mm ×35mm
*Official use only
or 2in x 1.4in

Surname (as shown in passport) ANISSA

Given and middle names (as shown in passport) FAUZIAH
Other names (including any other names you are or have been known by)

Date of birth 17/10/2001 Place of birth YOGYAKARTA

(Day)/(Month)/(Year) (City) (State or Province) (Country)
Sex: Male Female Marital status: Single Married Widowed Divorced
Nationality or citizenship INDONESIA
Former and/or other nationalities or citizenships
ID No. issued to you by your government 3471025710010001
Passport type: Diplomatic Official Ordinary Other Passport No. E5262677
Place of issue YOGYAKARTA Date of issue 30/11/2023
(Day)/(Month)/(Year)
Issuing authority Republic of Indonesia Directorate General of Immigratio Date of expiry 30/11/2033
(Day)/(Month)/(Year)
Purpose of visit to Japan Engineer/Specialist/ in Humanities/International Services
Intended length of stay in Japan 5 years
Date of arrival in Japan 25/03/2024
Port of entry into Japan Chubu Centrair-AP Name of ship or airline KE0628, KE0741
Names and addresses of hotels or persons with whom applicant intends to stay
Name Yoshinoryou Tel. +81-52-655-4918
3-10-29 Yoshino, Higashi-ku, Nagoya-shi 461-0027, Japan
Address
Dates and duration of previous stays in Japan -
Your current residential address (if you have more than one address, please list them all)
Cokrokusuman JT II no 922 Cokrodiningratan, Jetis, Yogyakarta
Address
Tel. +6285741234706 Mobile No. +6288227306303
E-Mail [email protected]
Current profession or occupation and position Company Employee, Engineer
Name and address of employer

Name CBS Techno Co., Ltd Tel. +81-52-655-4918

5-18 Ungacho, Nakagawa-ku, Nagoya, 454-0001 Japan
Address
 Partner's profession/occupation (or that of parents, if applicant is a minor):
(note 1)

Guarantor in Japan(Please provide details of the guarantor)

Name Xiao Wu Tel. +81-52-655-4918
5-18 Ungacho, Nakagawa-ku, Nagoya, 454-0001 Japan
Address
Date of birth 18/01/1986 Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant Employer of Applicant
Profession or occupation and position Company President
Nationality and immigration status China and permanent residence of Japan
Inviting Person in Japan(Please write 'same as above' if the inviting person and the guarantor are the same)
Name Xiao Wu Tel. +81-52-655-4918
5-18 Ungacho, Nakagawa-ku, Nagoya, 454-0001 Japan
Address
Date of birth 18/01/1986 Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant Employer of Applicant
Profession or occupation and position Company President
Nationality and immigration status China and permanent residence of Japan
Remarks/Special circumstances, if any
(note 1)

Have you ever:

● been convicted of a crime or offence in any country? Yes No
● been sentenced to imprisonment for 1 year or more in any country?(note 2) Yes No
● been deported or removed from Japan or any country for overstaying your visa or violating
any law or regulation? Yes No
● been convicted and sentenced for a drug offence in any country in violation of law
concerning narcotics, marijuana, opium, stimulants or psychotropic substances?(note 2) Yes No
● engaged in prostitution, or in the intermediation or solicitation of a prostitute for other
persons, or in the provision of a place for prostitution, or any other activity directly
connected to prostitution? Yes No
● committed trafficking in persons or incited or aided another to commit such an offence? Yes No
(note 2) Please tick “Yes” if you have received any sentence, even if the sentence was suspended.
If you answered “Yes” to any of the above questions, please provide relevant details.

“I hereby declare that the statement given above is true and correct. I understand that immigration status and period of stay to
be granted are decided by the Japanese immigration authorities upon my arrival. I understand that possession of a visa does not
entitle the bearer to enter Japan upon arrival at port of entry if he or she is found inadmissible.”
“I hereby consent to the provision of my personal information (by an accredited travel agent, within its capacity of representing
my visa application) to the Japanese embassy/consulate-general and (entrust the agent with) the payment of my visa fee to the
Japanese embassy/consulate-general, when such payment is necessary.”

Date of application 13/03/2024 Signature of applicant

(Day)/(Month)/(Year)
(note 1) It is not mandatory to complete these items.
Any personal information filled in this application as well as additional information submitted for the visa application (hereinafter
referred to as "Retained Personal Information”) will be handled appropriately in accordance with the Act on the Protection of
Personal Information Held by Administrative Organs (Act No. 58 of 2003, hereinafter, “the Act”). Retained Personal Information
will only be used to the extent necessary for the purpose of processing the visa application (including providing personal
information to the transportation company which you intend to board, or the alternative airline or ship which you initially did not
intend to board due to unforeseen circumstances) and for other purposes in compliance with Article 8 of the Act.