Biro Kerjasama dan Urusan Internasional Universitas Muhammadiyah Surakarta Jl. A. Yani No.157, Pabelan, Kartasura, Sukoharjo, Jawa Tengah 5716 9 Telp. +62271 717417 psw. 1 702 , 1701, 1707 . Fax. 0271 - 715448 Website: http:// bku i. ums.ac.id | E - mail: int.office @ums.ac.id VISA APPLICATION STATEMENT LETTER I the undersigned, Name : Sex : Place and Date of Birth : Nationality : Passport Number : Expiry Date : Hereby declare that 1. I am willingly monitored by the health authority during the quarantine period or self - isolation according to health protocol and Indonesian laws and regulations. 2. I am in possession of health insurance/travel insurance which covers all the medical expenses, and willingly pay the medical expenses at my own expenses s hould I am contacted by COVID - 19 virus while in Indonesia. This statement is made truthfully and to be used accordingly. Best Regards,