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Tanggal Cetak : 11/06/2017 13:29:08

REPUBLIC OF INDONESIA

MINISTRY OF HEALTH

Regency/Municipal Health Service 2800129972


of .............................................

TO WHOM IT MAY
CONCERN

Herewith the undersigned :

Name :

Address : Indonesia

NOTIFIES THAT

Name : MARTINI BINTI MAMAT ASNAWI

Passport : 0
Number

Flight :

for his/her own needs has to bring the following medicines

No. Items/kind of medicines Unit Amount

1 MULTIVITAMIN 30

2 GLIBENKLAMID 50

3 METFORMIN 50

Based on medical reasons, the above medicines are stricly prepared for daily
personal use by the bearer, and this notification is provided to be shown/produced
to the Saudi Arabian Authority when necessary uppon arrival for clearance

NIP/NRP

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