JABATAN IMIGRESEN MALAYSIA
BORANG PERMOHONAN VISA
* Jenis Permohonan
Type of Application
Dalam Malaysia
In Malaysia
MAKLUMAT PEMOHON
PARTICULARS OF APPLICANT
Nama Penuh (Huruf Besar)
Full Name (Capital Letter)
*Jantina
Gender
1.
2.
5.
3.
4.
6.
7.
7.a
8.
9.
10.
11.
12.
Tempat/Negara Lahir
Place/Country of Birth
**Tarikh Lahir
Date of Birth
hari
day
bulan
month
tahun
year
Warganegera
Nationality
Pekerjaan
Occupation
Alamat
Address
Telephone Nos.
Taraf Perkahwinan
Marital Status
Jenis Dokumen Perjalanan
Type of Travel Document
MAKLUMAR PASPORT PERJALANAN / DOKUMEN PERJALANAN
PARTICULARS OF PASSPORT / TRAVEL DOCUMENT
Nombor
Number
Tempat / Negara Dikeluarkan
Place / Country of lssue
**Sah Sehingga
Valid Until
hari
day
bulan
month
tahun
year
For Office Use Only
Belum Berkahwin
Single
Berkahwin
Married
Hand Phone:
Office:
Lelaki
Male
Perempuan
Female
Seberang Laut
Oversea
IM. 47-Pin. 1/97
Gambar
Pemohon
Photograph of
Applicant
(3.5 cm x 5.0 cm)
VISA APPLICATION FORM
A.
B.
13.
15.
14.
16.
17.
18.
C.
D.
BUTIR-BUTIR PENGANJUR DI MALAYSIA
NAME OF SCHOOL OR INVITING COMPANY IN MALAYSIA
BUTIR-BUTIR PERMOHONAN
DETAIL OF APPLICATION
Name Penuh (Huruf Besar)
Full Name (Capital Letter)
No. Kad Pengenalan
NRIC
Alamat
Address
Tempoh Tinggal Yang Dicadangkan
Duration of Proposed Stay
Bulan
Month
Bercuti
Holiday
Transit
Transit
Urusan Rasmi
Official Trip
Persidangan
Conference
Belajar
Study
..............................................................
Tandatangan Pemohon / Penganjur
Signature of Applicant / Sponsor
.......................
Tarikh
Date
Borang ini hendaklah ditaip. Tandakan (x) dalam petak yang berkenaan.
This form should be typed. Mark (x) in the appropriate box.
**Format Tarikh 99/99/9999
Date Format DD/MM/YYYY
Urusan Perniagaan
Business
Melawat Saudara Mara / Kawan
Visiting Friends / Relatives
Bekerja
Employment
Lain-Lain (Nyatakan)
Others (Specity)
Negeri
State
No. Telefon
Telephone No.
dd mmm yyyy
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Malaysia Visa Application Form

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Completed 2 March 2020

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