FOURSQUARE CONNECTION 25 Mei - 8 Juni, SEATTLE, USA

FOURSQUARE CONNECTION  25 Mei - 8 Juni,  SEATTLE, USA

KESEMPATAN UNTUK MENDAFTARKAN DIRI MENJADI  DELEGASI INDONESIA DI FOURSQUARE CONNECTION 2018 (SEATTLE) SAMPAI SENIN 7 MEI 2018 JAM 12.00 WIB

 *CONTOH PENGISIAN FORM ONLINE DS-160

(Ini hanya contoh, tolong diisi sesuai dengan data pribadi masing-masing delegasi. Kalau ada kebingungan silakan meniru contoh pengisian. Atau bisa SMS ke 082226479214 atau email ke: departemen.LN@gpdi.or.id atau send message ke FB Departemen Luar Negeri - MP GPdI)
 
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Name Provided:
MICHAEL, DONNY
 
Full Name in Native Alphabet:
DONNY MICHAEL
 
Other Names Used:
NO
 
Telecode Name Used:
NO
 
Sex:
MALE
 
Marital Status:
MARRIED
 
Date of Birth:
03 OCTOBER 1991
 
Country/Region of Birth:
JAKARTA, DKI JAYA, INDONESIA
 
Country/Region of Origin (Nationality):
INDONESIA
 
Do you hold or have you held any nationality other than the one indicated above on nationality?
NO
 
Are you a permanent resident of a country/region other than your country/region of origin (nationality) above?
NO
 
National Identification Number:
3175010310910005
 
U.S. Social Security Number:
DOES NOT APPLY
 
U.S. Taxpayer ID Number:
DOES NOT APPLY
 
Home Address:
Jl. H.R. Rasuna Said Kav. C-22 A
 
City:
JAKARTA
 
State/Province:
DKI JAYA
 
Postal Zone/ZIP Code:
12940
 
Country/Region:
INDONESIA
 
Same Mailing Address?
YES
 
Primary Phone Number:
6281222220144
 
Secondary Phone Number:
DOES NOT APPLY
 
Work Phone Number:
DOES NOT APPLY
 
Email Address:
 
Passport/Travel Document Type:
REGULAR
 
Passport/Travel Document Number:
B7532812
 
Passport Book Number:
1A13J28459DVRW
 
Country/Authority that Issued Passport/Travel Document:
INDONESIA
 
City where issued:
JAKARTA
 
State/Province where issued:
DKI JAYA
 
Country/Region where issued:
INDONESIA
 
Issuance Date:
15 JANUARY 2018
 
Expiration Date:
15 JANUARY 2023
 
Have you ever lost a passport or had one stolen?
NO
 
Purpose of Trip to the U.S. (1):
TEMP. BUSINESS PLEASURE VISITOR (B)
 
Specify:
BUSINESS & TOURISM (TEMPORARY VISITOR) (B1/B2)
 
Have you made specific travel plans?
NO
 
Intended Date of Arrival:
27 MAY 2018
 
Intended Length of Stay in U.S.:
2 WEEK(S)
 
Address where you will stay in the U.S.:
WESTIN SEATTLE
1900 5TH AVE
SEATTLE, WASHINGTON 98101
 
Person/Entity Paying for Your Trip:
SELF
 
Other Persons Traveling with You:
YES
 
Are you traveling as part of a group or organization?
YES
 
Name of the Group:
INDONESIAN FOURSQUARE CHURCH - GPDI
 
Have you ever been in the U.S.?
NO
 
Have you ever been issued a U.S. visa?
NO
 
Have you ever been refused a U.S. Visa, or been refused admission to the United States, or withdrawn your application for admission at the port of entry?
NO
 
Has anyone ever filed an immigrant petition on your behalf with the United States Citizenship and Immigration Services?
NO
 
Contact Person Name in the U.S.:
SUWUH, JOHANNIS
 
Organization Name in the U.S.:
GPDI-FOURSQUARE WASHINGTON
 
Relationship to You:
BUSINESS ASSOCIATE
 
U.S. Contact Address:
2007 104TH ST SW
EVERETT, WASHINGTON 98204
 
Phone Number:
4254380145
 
Email Address:
 
Father's Surnames:
MICHAEL
 
Father's Given Names:
DIETHER
 
Father's Date of Birth:
01 JANUARY 1946
 
Is your father in the U.S.?
NO
 
Mother's Surnames:
ARYANI
 
Mother's Given Names:
HARYATI
 
Mother's Date of Birth:
15 OCTOBER 1957
 
Is your mother in the U.S.?
NO
 
Do you have any immediate relatives, not including parents in the U.S.?
NO
 
Do you have any other relatives in the United States?
YES
 
Spouse's Full Name:
MARIA, ANNA
 
Spouse's Date of Birth:
25 DECEMBER 1995
 
Spouse's Country/Region of Origin (Nationality):
INDONESIA
 
Spouse's City of Birth:
JAKARTA
 
Spouse's Country/Region of Birth:
INDONESIA
 
Spouse’s Address:
SAME AS HOME ADDRESS
 
Primary Occupation:
RELIGIOUS VOCATION
 
Present Employer or School Name:
GPDI JAKARTA
 
Present Employer or School Address:
Jalan Danau Sunter Selatan, Blok E, No. 1
 
City:
JAKARTA
 
State/Province:
DKI JAYA
 
Postal Zone/Zip Code:
14350
 
Country/Region:
INDONESIA
 
Start Date:
01 JANUARY 2011
 
Work Phone Number:
62216459330
 
Monthly Salary in Local Currency (if employed):
DOES NOT APPLY
 
Briefly Describe your Duties:
I AM SERVING AS A DEPUTY OF SENIOR PASTOR
 
Were you previously employed?
NO
 
Show/Hide  Have you attended any educational institutions at a secondary level or above?
YES
 
Name of Institution (1):
SMA DON BOSCO II
 
Address of Institution:
Jl Pulomas Barat V Kayu Putih
 
City:
JAKARTA
 
State/Province:
DKI JAYA
 
Postal Zone/ZIP Code:
13210
 
Country/Region:
INDONESIA
 
Course of Study:
SOCIAL
 
Date of Attendance From:
01 JUNE 2007
 
Date of Attendance To:
01 JUNE 2010
 
Do you belong to a clan or tribe?
NO
 
Show/Hide  Provide a List of Languages You Speak:
Language Name (1):
BAHASA INDONESIA
 
Show/Hide  Have you traveled to any countries/regions within the last five years?
YES
 
Provide a List of Countries/Regions Visited
Country/Region(1):
SINGAPORE
 
Show/Hide  Have you belonged to, contributed to, or worked for any professional, social, or charitable organization?
YES
 
Name of Organization (1):
GPDI - INDONESIAN FOURSQUARE
 
Do you have any specialized skills or training, such as firearms, explosives, nuclear, biological, or chemical experience?
NO
 
Have you ever served in the military?
NO
 
Have you ever served in, been a member of, or been involved with a paramilitary unit, vigilante unit, rebel group, guerrilla group, or insurgent organization?
NO
 
Do you have a communicable disease of public health significance? (Communicable diseases of public significance include chancroid, gonorrhea, granuloma inguinale, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, active tuberculosis, and other diseases as determined by the Department of Health and Human Services.)
NO
 
Do you have a mental or physical disorder that poses or is likely to pose a threat to the safety or welfare of yourself or others?
NO
 
Are you or have you ever been a drug abuser or addict?
NO
 
Have you ever been arrested or convicted for any offense or crime, even though subject of a pardon, amnesty, or other similar action?
NO
 
Have you ever violated, or engaged in a conspiracy to violate, any law relating to controlled substances?
NO
 
Are you coming to the United States to engage in prostitution or unlawful commercialized vice or have you been engaged in prostitution or procuring prostitutes within the past 10 years?
NO
 
Have you ever been involved in, or do you seek to engage in, money laundering?
NO
 
Have you ever committed or conspired to commit a human trafficking offense in the United States or outside the United States?
NO
 
Are you the spouse, son, or daughter of an individual who has committed or conspired to commit a human trafficking offense in the United States or outside the United States and have you within the last five years, knowingly benefited from the trafficking activities?
NO
 
Have you knowingly aided, abetted, assisted or colluded with an individual who has committed or conspired to commit a severe human trafficking offense in the United States or outside the United States?
NO
 
Do you seek to engage in espionage, sabotage, export control violations, or any other illegal activity while in the United States?
NO
 
Do you seek to engage in terrorist activities while in the United States or have you ever engaged in terrorist activities?
NO
 
Have you ever or do you intend to provide financial assistance or other support to terrorists or terrorist organizations?
NO
 
Are you a member or representative of a terrorist organization?
NO
 
Have you ever ordered, incited, committed, assisted, or otherwise participated in genocide?
NO
 
Have you ever committed, ordered, incited, assisted, or otherwise participated in torture?
NO
 
Have you committed, ordered, incited, assisted, or otherwise participated in extrajudicial killings, political killings, or other acts of violence?
NO
 
Have you ever engaged in the recruitment or the use of the child soldiers?
NO
 
Have you, while serving as a government official, been responsible for or directly carried out, at any time, particularly severe violations of religious freedom?
NO
 
Have you ever been directly involved in the establishment or enforcement of the population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or her free will?
NO
 
Have you ever been directly involved in the coercive transplantation of human organs or bodily tissue?
NO
 
Have you ever sought to obtain or assist others to obtain a visa, entry into the United States, or any other United States immigration benefit by fraud or willful misrepresentation or other unlawful means?
NO
 
Have you ever withheld custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court?
NO
 
Have you voted in the United States in violation of any law or regulation?
NO
 
Have you ever renounced United States citizenship for the purpose of avoiding taxation?
NO
 
Location where you will be submitting your application
Current Location:
JAKARTA, INDONESIA
 
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FOURSQUARE CONNECTION 2018 adalah acara internasional yang dilakukan setiap tahun oleh Foursquare Church International. Pesertanya adalah delegasi-delegasi Gereja Foursquare dari seluruh dunia. GPdI menjadi rekanan Foursquare Church International sejak tahun 2005. GPdI-Foursquare adalah nama institusi kerjasama antara dua organisasi Gereja ini di Amerika Serikat.

Bapak-Ibu anggota GPdI yang akan bergabung untuk menjadi delegasi Indonesia di acara Foursquare Connection 2018 harap mengirim kelengkapan data sebagai berikut:

  • Nama lengkap sesuai paspor.
  • Nomor paspor.
  • Expire date paspor adalah 6 (enam) bulan dari tgl pulang ke Indonesia.
  • Expire date USA visa adalah tgl pulang ke Indonesia.

PENGUMPULAN DATA. Semua kelengkapan data bisa dikirimkan melalui SALAH SATU dari beberapa cara dibawah ini:

KEBERANGKATAN. Rombongan delegasi yang dikoordinasi oleh Departemen Luar Negeri rencananya akan berangkat tanggal 25-Mei-2018 dan pulang tanggal 8-Juni-2018. Durasi 2 minggu dimaksudkan untuk memberi kesempatan delegasi mengeksplorasi Amerika Serikat. Perlu diingat Departemen Luar Negeri hanya akan membantu administrasi dan teknis selama rangkaian Foursquare Connection 2018 saja (28-31 Mei 2018).

Untuk kegiatan SESUDAH tanggal 31 Mei, termasuk akomodasi, perjalanan, pergi ke kota lain, perpanjangan tinggal atau pulang lebih cepat dan semua biaya yang menyertainya hanya akan mendapat arahan dan bantuan saran dari kami, tetapi TIDAK MENJADI TANGGUNG JAWAB Departemen Luar Negeri.

PENGURUSAN VISA. Departemen Luar Negeri berusaha semaksimal mungkin untuk membantu mendapatkan surat referensi dari Foursquare Church International, bagi keperluan pengurusan VISA. Kami sudah menghubungi salah satu travel yang menyatakan bahwa “Appointment for Interview” di Kedubes AS sudah sampai di 21 Mei 2018. Sementara waktu sampai VISA keluar adalah 3 hari kerja. Jadi kami hanya akan membantu mengurus tetapi tidak menjamin bahwa VISA delegasi akan terbit tepat waktu. SEMUA TANGGUNG JAWAB ADA PADA DELEGASI YANG BERSANGKUTAN. Minggu 6-Mei-2018 pendaftaran resmi untuk Delegasi GPdI akan ditutup.

PERKIRAAN BIAYA. Estimasi tiket penerbangan pp adalah Rp.18.000.000,-, pendaftaran Foursquare Connection adalah Rp.2.500.000,- dan penginapan (hanya selama Foursquare Connection) Rp.1.100.00,- per malam, sharing 2 pax/room (Fousquare Connection berlangsung 3 malam). Semua biaya makan, tips, transportasi pribadi akan menjadi tanggungan peserta yang bersangkutan. Sehingga untuk sampai selesainya Foursquare Connection per delegasi akan menghabiskan biaya ± Rp.30.000.000,- (semua tergantung bagaimana delegasi mengatur pengeluaran).

*Pasport harus masih berlaku selama 6 bulan dari tanggal pulang ke Indonesia

MARI NIKMATI PENGALAMAN BERSAMA DENGAN RIBUAN HAMBA TUHAN DARI SELURUH DUNIA DI FOURSQUARE CONNECTION 2018. DAFTARKAN DIRI ANDA SEGERA!

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