A. Personal Details

Full Name *


Sex *

Passport Number

Present Addres

Phone / WhatsApp *

Email *

Adress in Yogyakarta (if any)

Company / Organization



In Case Of Emergency First Person To Contact Is

His or Her phone / fax *

B. Term Of Payment

Paid By

Paid upon my arrival with

C. Visa

We need your arrangement and sponsorship of an application for 6 month Social-Culture Visa or 1 year visa:

If so, from wich Indonesian embassy or consulate do you intend to get your visa (city/country):

D. Language Program

Approximate date of arrival

Approximate date of starting the class

Approximate date of completing the program

Have you taken an Indonesian language training

If so, how long ?

Level to start at Puri Bahasa Indonesia

How many hours per day to learn Indonesian at Puri Bahasa Indonesia

Prefered Schedule for your class

8 AM - 12 AM10 AM - 1 PM1 PM - 3 PM2 PM - 4 PM8 AM - 11 AM10 AM - 12 PM11 AM - 1 PM1 PM - 4 PM2 PM - 5 PMAny time

Saturday Classes?

You may add the following classes within your learning hours:

Borobudur Temple for 4 hoursPrambanan Temple For 4 hours:Traditional Market for 2 hours:Sultan Palace for 2 hours:Imogiri Royal Palace for 2 hours:Beaches for 4 hoursLive in a village for 4 hours

E. Accomodation

I plan to stay at

If you stay at Puri Guest House


F. Others

The purpose of learning Indonesian. Please, state in English:

Special request for language training. Please, state in English:

Cultural activities, excluding the learning hours :

Batik Class for 2 hoursDancing class for 2 hoursCooking class for free of chargeRamayana BalletPractising Gamelan and watching feather Puppet ShowWood carving mask class ( 8 hours )