FOREIGN NATIONALS LETTER OF DOMICILE (FNLoDo)
NOTES:
1. The form is to be filled out using CAPITAL letters;
2. Applicants Not allowed to use Short Writing;
3. Applicants are mandatory to bring supporting documents/certificate from the head of the community unit
    (Ketua RT/RW), Photocopy of Passport/KITAS/KITAP;
4. Make sure again that the form that is filled in is in accordance with your needs. If it is appropriate then press
    SUBMIT/KIRIM at the bottom of this form.
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Email *
Kode Surat Keterangan *
Beri tanda cek pada keterangan ini
Required
Nomor Paspor/KITAS/KITAP *
Passport/KITAS/KITAP number
Nama Lengkap *
Full Name
Tempat Lahir *
Place of birth
Tanggal Lahir *
Date of birth
MM
/
DD
/
YYYY
Jenis Kelamin *
Sex : LAKI-LAKI for Male and PEREMPUAN for Female
Golongan Darah *
Blood Type
A
B
AB
O
A+
A-
B+
B-
AB+
AB-
O+
O-
TIDAK TAHU
Tipe
Alamat *
Notes: Fill in the name of the Current Address by street/complex or housing residences
RT / RW *
Notes : Fill in the current number of the neighborhood (Rukun Tetangga) and community (Rukun Warga) units
001
002
003
004
005
006
007
00...
Rukun Tetangga
Rukun Warga
Asal Kelurahan *
Notes : Fill in the current Urban Village Name
Asal Distrik/Kec. *
Notes : Fill in the current Sub Urban District Name
Asal Kab./Kota *
Notes : Fill in current City Name
Status Agama *
Notes : Fill in Religion Status
BUDHA
HINDU
ISLAM
KATHOLIK
KRISTEN
KONGHUCHU
KEPERCAYAAN LAINNYA
Agama
Status Perkawinan *
Marital Status : BELUM KAWIN (UNMARRIED), KAWIN (MARRIED), CERAI HIDUP (DIVORCED) or CERAI MATI (DIVORCED BECAUSE OF DEATH)
Pekerjaan *
Occupation
Status Kewarganegaraan *
Nationality
For the Purpose Letter *
Notes : Fill The Requirements of the ...... At (Name Of The Institution addressed), Appicant allowed to describe in English or Indonesian lenguage
Dokumen Pelengkap *
Notes : Documents/Covering letter from the head of the community unit (Ketua RT/RW) that must be brought by the applicant to Kelurahan Koya Barat office
Ada (possess)
Tidak Ada (unpossess)
Covering letter from the head of the community unit (Ketua RT/RW)
Photocopy of Passport/KITAS/KITAP
Nomor Telepon/HP *
Phone Numbers
Submit
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