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Visa Application

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Visa Application

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23stacks
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VISA APPLICATION FORM TO ENTER JAPAN

(Paste photo here)

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

Surname (as shown in passport) TKACHEV


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

Date of birth 03.08.1985 Place of birth CHELYABINSKAYA OBL./USSR


(Day)/(Month)/(Year) (City) (State or Province) (Country)
Sex: Male Female Marital status: Single Married Widowed Divorced
Nationality or citizenship RUSSIA
Former and/or other nationalities or citizenships
ID No. issued to you by your government IM2XBN77953
Passport type: Diplomatic Official Ordinary Other Passport No. 661909547
Place of issue Saint-Petersburg, Russia Date of issue 16/09/2021
(Day)/(Month)/(Year)
Issuing authority Ministry of Internal Affairs (0593) Date of expiry 16/09/2026
(Day)/(Month)/(Year)
Certificate of Eligibility No. -
Purpose of visit to Japan/Status of residence TOURISM
Intended length of stay in Japan 11 days Date of arrival in Japan 01/11/2024
Port of entry into Japan Osaka-Kansai Name of ship or airline VJ 938
Names and addresses of hotels or persons with whom applicant intends to stay
Name R HOTEL HONMACI Tel. +81 662661515
Chuo-ku, Bakuromachi 1-7-15,
Address Chuo Ward, Osaka, 541-0059, Japan
Dates and duration of previous stays in Japan 24/09/2018 - 30/09/2024 (6 days)
Your current residential address (if you have more than one address, please list them all)
CEMARA HOME, Jl. Umalas 1 No.46, Kerobokan Kelod, Kec. Kuta Utara, Kabupaten Badung,
Address Bali 80361, Indonesia
Tel. +62881038294329 Mobile No. +62881038294329
E-Mail [email protected]
Current profession or occupation and position INVESTOR (KOMISARIS)
Name and address of employer

Name PT SUNLIGHT LUXURY RENTAL Tel. +62 08194350568


Jalan Batur Sari Gang Kepah Nomor 108, Desa/Kelurahan Sanur Kauh, Kec.
Address Denpasar Selatan, Kota Denpasar, Provinsi Bali
(Note)Partner's profession/occupation (or that of parents, if applicant is a minor):
-
Guarantor or reference in Japan(Please provide details of the guarantor or the person to be visited in Japan)
Name - Tel. -

Address -
Date of birth - Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant -
Profession or occupation and position -
Nationality and immigration status -
Inviter in Japan(Please write 'same as above' if the inviting person and the guarantor are the same)
Name - Tel. -

Address -
Date of birth - Sex: Male Female
(Day)/(Month)/(Year)
Relationship to applicant -
Profession or occupation and position -
Nationality and immigration status -
(Note)Remarks/Special circumstances, if any -
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 23/10/2024 Signature of applicant


(Day)/(Month)/(Year)
(Note)It is not mandatory to complete these items.

Any personal information filled in this application form as well as additional personal information submitted for the visa
application (hereinafter referred to as "Retained Personal Information?) will be handled appropriately by the Ministry of Foreign
Affairs of Japan (including Japanese overseas establishments) in accordance with the Act on the Protection of Personal
Information (Act No. 57 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 are going to travel with, or the alternative transportation company which you are going to travel with due to
unforeseen circumstances), immigration control, international cooperation and for other purposes in compliance with Article 69
of the Act.

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