DAFTAR RIWAYAT HIDUP CURRICULUM VITAE

Transcription

1 DAFTAR RIWAYAT HIDUP CURRICULUM VITAE FORM 1 1. Nama Lengkap :... Alias / Other Name : Tempat & Tanggal lahir :... Place & Date of Birth 3. Kebangsaan :... Nationality 4. No. Paspor & Masa Berlaku :... Passport No. & Validity 5. Alamat, No. Telepon & Orang yg dihubungi dlm kondisi darurat :... Contact person in case of emergency Alamat, No. Telepon & 7. Status Perkawinan :... Marital Status Nama istri/suami :... Spouse Name 8. Pengalaman Militer :... Military Record 9. Riwayat Pendidikan :... Education 10. Riwayat Pekerjaan :... Employment record... * use additional sheet if necessary

2 FORM 2 PERMOHONAN IZIN KUNJUNGAN JURNALISTIK APPLICATION FOR JOURNALISTIC VISIT 1. Nama Lengkap : 2. Tempat & Tanggal Lahir : Place & Date of Birth 3. Kebangsaan : Nationality 4. No. Paspor & Masa Berlaku : Passport No. & Validity 5. Alamat, No. Telepon & 6. Tanggal & Tempat Kunjungan Jurnalistik ke Indonesia Sebelumnya :... Date & Place of Previous Journalistic visit to Indonesia 7. Rencana Tanggal & Tempat Kunjungan Jurnalistik ke Indonesia :... Proposed Date & Place of Journalistic visit to Indonesia 8. Jumlah rekan pada kunjungan jurnalistik ke Indonesia :... No. of crew travelling together to Indonesia 9. Nama Perusahaan : Company Name 10. Jabatan dalam perusahaan : Position within the Company 11. Alamat, No.Telepon & Kantor : Address, Phone No. & Office 12. Nama & Alamat Bank Penjamin di Inggris :... Name & Address of UK Bank guarantee 13. Tujuan & Judul Produksi : Production Purposes & Title

3 14. Penanggung jawab Produksi : Head/Person in charge of the production Alamat, No. Telepon & Tanggal & Media Penyiaran hasil Produksi :... Date & Broadcasting Media of Production 16. Nama & Perusahaan Fixer di Indonesia :... Name & Company of fixer in Indonesia Alamat, No. Telepon & Nama & instansi mitra di Indonesia : Name & institution of Indonesian counterpart Alamat, No. Telepon & Alamat tempat tinggal di Indonesia :... Address of accommodation in Indonesia Date : (Name & Signature)

4 DAFTAR REKAN KERJA PRODUKSI PRODUCTION CREW MEMBERS FORM 3 Nama Lengkap :... Jabatan :... Occupation Paspor (nomor, tempat & tanggal dikeluarkan) :... Passport (number, place & date of issue) Nama Lengkap :... Jabatan :... Occupation Paspor (nomor, tempat & tanggal dikeluarkan) :... Passport (number, place & date of issue) Nama Lengkap :... Jabatan :... Occupation Paspor (nomor, tempat & tanggal dikeluarkan) :... Passport (number, place & date of issue)......

5 FORM 4 JADWAL PRODUKSI PRODUCTION TIME TABLE No. Tanggal Date Tempat Location Kegiatan Activity

6 LATAR BELAKANG CERITA / RINGKASAN STORY BOARD / SYNOPSIS FORM 5

7 FORM 6 DAFTAR NARA SUMBER LIST OF RESOURCE PERSONS/INTERVIEWEES No. Nama Lengkap Pekerjaan Occupation Instansi/Perusahaan Company/Institution Alamat, No. Telepon &

8 FORM 7 DAFTAR PERALATAN PRODUKSI PRODUCTION LIST OF EQUIPMENTS No. Peralatan Equipments Jumlah Quantity Berat Weight (kg) Nilai Value (US$) Negara Asal Country of Origin Date : (Name & Signature)

9 FORM 8 A Statement for coverage application (news coverage, photos, cameras and foreign correspondents) STATEMENT To complete application for journalist visit permit in Indonesia, I/we hereby declare that we shall : 1. Observe and agree to all relevant national and local regulations of the Government of the Republic of Indonesia on holy places, national parks, and other intended places; 2. Bear all expenses during duration of journalist activities; 3. Not cover strategic/vital objects/locations; 4. Re-export all equipment at own expenses upon completion of journalist visit and bear all related costs...., / Company Name : Address : Signature : Name : Title : Tel. :

10 FORM 8 B Statement for filming application (film shooting/documentary/reality show/commercial advertising) STATEMENT To complete our application for film/video/documentary shooting permit in Indonesia, I/we hereby declare that we shall : 1. Comply with laws and regulations of the Government of the Republic of Indonesia. 2. Report upon arrival to the Ministry of Education and Culture c.q. Film Development Center to obtain details of central and local rules before filming begins. 3. Report to the Information Services of the Provinces/Regional Government that will appoint a liaison officer and bear all expenses related to the services, or appointed by Film Development Center. 4. Appoint a local partner or fixer. 5. Conduct shooting in accordance with the proposed script/synopsis and object/locations as set out in the shooting permit issued by the Ministry of Education and Culture. 6. Not film strategic/vital objects/and locations. 7. Apply for the Conservation Area Entry Permit (Surat Izin Masuk Kawasan Konservasi - SIMAKSI) at the Ministry of Environment and Forestry, if applicable. 8. Bear all expenses towards taking objects/locations which have specific rules and if deemed necessary, additional expenses will also be borne. 9. Re-export all shooting equipment at your own expense upon completion of filming and bear all related costs on CBP/ATA Carnet. 10. Submit 1(one) released copy of film/video to the Ministry of Education and Culture c.q. Film Development Center through the Embassy of the Republic of Indonesia/Consulate General of the Republic of Indonesia which may be used at the discretion of Government of the Republic of Indonesia for non-commercial purposes. Name of company : Name :.... Signature Address : Telephone : Facsimile : *ANY CHANGE OF SCHEDULE AND LOCATION SHOULD BE SUBMITTED THROUGH THE INDONESIAN EMBASSY/CONSULATE GENERAL/CONSULATE date