GROUP REQUEST FORM

‫إﺳﺘﻤﺎرة ﺣﺠﺰ ﻣﻮﻋﺪ ﻟﻠﻤﺠﻤﻮﻋﺔ‬

GROUP ID ‫رﻗﻢ اﻟﻤ ﻮﻋﺪ ﻟﻠﻤﺠﻤ ﻮﻋﺔ‬

D ate : 19-Mar-2019 Ti m e : 10:56

Appointment Agent Name &

Type GROUP ID PT Albis Nusa Wisata
Albis
‫ﻧﻮع اﻟﻤﻮﻋﺪ‬ ‫إﺳﻢ اﻟﻮﻛﯿﻞ‬
‫ورﻗﻤﻪ‬
Appointment Category NORMAL LOUNGE No. of Applicants
‫ﻓﺌﺔ اﻟﻤﻮﻋﺪ‬ ‫ﻋﺪد ﻣﻘﺪﻣﻲ اﻟﻄﻠﺒﺎت‬ 2

Appointment Date
‫ﺗﺎرﯾﺦ اﻟﻤﻮﻋﺪ‬ 20-Mar-2019 Visa Service Center Kantor Pos Purwokerto Selatan Jalan
Address Sultan Agung No 50 Teluk Kecamatan
Appointment Time
‫اﻟﻮﻗﺖ اﻟﻤﺤﺪد ﻟﻠﻤﻮﻋﺪ‬
10:15 ‫ﻋﻨﻮان ﻣﺮﻛﺰ ﺧﺪﻣﺔ‬ Purwokerto Selatan Kab Banyumas,
‫اﻟﺘﺄﺷﯿﺮات‬
53145

S .No. A p p Ref No. P as s p ort Numb er Name A p p ointment Time

1 C3236115 MA HANAFI 10:15

2 C3236999 JASIRUN SUMIRMO 10:15

The consolidated amount to be paid at the VSC center is displayed below

‫ﯾﺘﻢ دﻓﻊ ﻣﺠﻤﻮع اﻟﻤﺒﺎﻟﻎ اﻟﻤﺬﻛﻮر ة أدﻧﺎ ه ﻓﻲ ﻣﺮﻛﺰ ﺧﺪﻣﺔ اﻟﺘﺄ ﺷﯿﺮات‬
Name Unit Fee(in ID R) No. of A p p lic ants A mount in ID R
‫اﻹﺳﻢ‬ ‫ﻋﺪد ﻣﻘﺪﻣ ﻲ اﻟ ﻄﻠﺒﺎت‬

Agent Bio Normal 104545.00 2 209090.00

10.00 % for Agent Bio

VAT 2 20909.00
Normal

Total 229,999.00

To Be Paid 229,999.00
Ins truc tions : ‫ا ﻟﺘﻌ ﻠﯿﻤ ﺎت‬
1. If granted the visa I shall abide by all the laws and regulations of the Kingdom of Saudi Arabia and respect the Islamic customs and traditions of its people.

‫ ﻓﻲ ﺣﺎل ﺣﺼﻮﻟﻲ ﻋﻠﻰ اﻟﺘﺄﺷﯿﺮة ﻋﻠﻲ أن أﻟﺘﺰم ﺑﺠﻤﯿ ﻊ اﻟ ﻘﻮاﻧﯿﻦ واﻷﻧﻈﻤﺔ اﻟﻤﻌﻤﻮل ﺑﻬﺎ ﻓﻲ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ وإﺣﺘﺮام اﻟﻌﺎدات واﻟﺘ ﻘﺎﻟﯿﺪ اﻹﺳﻼﻣﯿﺔ ﻟﺸﻌﺒﻬﺎ‬.

2. I am also fully aware that the crime of smuggling narcotics and other illegal drugs into the Kingdom of Saudi Arabia is punishable by the death penalty.

‫إﻧﻨﻲ أدرك ﺗﻤﺎﻣﺎ أن ﺟﺮﯾﻤﺔ ﺗﻬﺮﯾﺐ اﻟﻌ ﻘﺎ ﻗﯿﺮ اﻟﻤﺨﺪرة واﻟﻤﺨﺪرات ﻏﯿﺮ اﻟﻤﺸﺮوﻋﺔ اﻷﺧﺮى إﻟﻰ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ ﻣﻌﺎ ﻗﺐ ﻋﻠﯿﻬﺎ ﺑﺎﻹﻋﺪام‬.

3. I have never been removed, excluded or deported from the Kingdom of Saudi Arabia or from any other G ulf Cooperation Council member state or
charged with violation of any law or regulation thereof.
 ‫‪.‬ﻟﻢ ﯾﺴﺒﻖ أن ﺗﻢ إﺳﺘﺒﻌﺎدي أو ﺗﺮﺣﯿﻠﻲ ﻣﻦ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ أو ﻣﻦ أي دوﻟﺔ ﻋﻀﻮ ﻓﻲ ﻣﺠﻠﺲ اﻟﺘﻌﺎون ﻟﺪول اﻟﺨﻠﯿﺞ اﻟﻌﺮﺑﯿﺔ أو ﺗﻢ إﺗﻬﺎﻣﻲ ﺑﻤﺨﺎﻟ ﻔﺔ أي ﻣﻦ ﻗﻮاﻧﯿﻨﻬﺎ أو أﻧﻈﻤﺘﻬﺎ‬

‫‪4. I am aware that all alcoholic everages, narcotics and other illegal drugs, pornographic materials or publications, which violate the social norms of decency‬‬
‫‪and all other publications, which are disrespectful of any religious belief or political orientation, are prohibited and shall not be brought into the Kingdom of‬‬
‫‪Saudi Arabia‬‬

‫أﻧﺎ أدرك ﺗﻤﺎﻣﺎ أن ﺟﻤﯿ ﻊ اﻟﻤﺸﺮوﺑﺎت اﻟﻜﺤﻮﻟﯿﺔ‪ ،‬اﻟﻤﺨﺪرات واﻟﻌ ﻘﺎ ﻗﯿﺮ اﻟﻐﯿﺮ ﻗﺎﻧﻮﻧﯿﺔ اﻷﺧﺮى‪ ،‬اﻟﻤﻮاد اﻹﺑﺎﺣﯿﺔ ﻣﻦ رﺳﻮﻣﺎت أو أﻋﻤﺎل ﻋﺎﻣﺔ‪ ،‬واﻟﺘﻲ ﺗﻨﺘﻬﻚ اﻷﻋﺮاف اﻻﺟﺘﻤﺎﻋﯿﺔ ﻣﻦ اﻟﺤﺸﻤﺔ وﺟﻤﯿ ﻊ اﻹﺟﺮاءات اﻟﻌﺎﻣﺔ اﻷﺧﺮى وﻋﺪم‬
‫‪.‬إﺣﺘﺮام أي ﻣﻌﺘ ﻘﺪ دﯾﻨﻲ أو ﺗﻮﺟﻪ ﺳﯿﺎﺳﻲ‪ ،‬أﻣﻮر ﻣﺤﻈﻮرة ﻻ ﯾﺠﻮز إدﺧﺎﻟﻬﺎ اﻟﻰ اﻟﻤﻤﻠﻜﺔ اﻟﻌﺮﺑﯿﺔ اﻟﺴﻌﻮدﯾﺔ‬