Tanggal Cetak : 13/05/2017 21:15:05

REPUBLIC OF INDONESIA

MINISTRY OF HEALTH

Regency/Municipal Health Service 2800106871

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

TO WHOM IT MAY
CONCERN

Herewith the undersigned :

Name : dr.prihana novayanti

Address : Indonesia

NOTIFIES THAT

Name : FARIDHAH BINTI M.JUNAEDI KHANAFI

Passport : 0
Number

Flight :

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

No. Items/kind of medicines Unit Amount

1 omeprazol 30

2 ranitidin 30

3 lambucid 30

4 caviplex 30

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

dr.prihana novayanti

NIP/NRP