| 1. Arrival date in Indonesia: |
Date:
Month:
Year:
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| 2. Flight / Voyage Number: |
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| 3. Full Name: |
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| 4. Nationality: |
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| 5. Passport Number: |
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| 6. Occupation: |
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| 7. Address in Indonesia: |
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| 8. Number of accompanying
members (only for passenger): |
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| 9. Number of accompanied
baggages: |
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| NOTICE |
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- Each arriving crew / passenger must submit customs declaration
(onlyone Customs Declaration per family is required).
- Should have dutiable goods to be reexported please contact
Customs.
- Any undeclared dutiable goods will be considered as violation
and subject to administrative fine.
- Severe punishment for drug traffickers.
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Please answer the following questions. Fill
check mark (v) in the boxes.
If you tick Yes to any of the following questions please go to
the red channel.
If you are not sure about it, tick Yes.
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| Do you have with you: |
Yes No |
| 10. Good obtained overseas
exceeding FOB US $50 for crew, or US$ 250 per person or US$ 1,000
perfamily? (1) |
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| 11. More than 200 cigarettes
or 50 cigar or 200 grams sliced tabacco or 1 liter of alchoholic
beverages?(2) |
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| 12. Animal, fish, and plants
including their products?(3) |
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| 13. Narcotic drugs, psychotropic
substances, fire arms, weapons, ammunition, explosives, pornographic
materials?(4) |
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| 14. Cinematographic films,
pre recorded video tapes, video laser discs or records?(5) |
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| 15. Bank Notes in Rupiah
or other currency equal to 100 million Rupiah or more? |
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Note:
(1) subject to import duty
(2) shall be destroyed under Customs
control
(3) subject to quarantine inspection
(4) prohibited goods
(5) must be cencored |
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CUSTOMS DECLARED GOODS
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If you answered Yes to any of the previous
questions please provide details below.
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Description
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Quantity
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Value
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I declare that information given is true
and correct.
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| Please fill the form completely!! |
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| Click here to view the original form: page
1 - page
2 |
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