Regency Municipal Health Service

of Port Health Office Class I of Surabaya

TO WHOM IT MAY CONCERN

Herewith the undersigned :

Name :

Occupation : Port Health Medical Officer

Address : Port Health Office Class I of Surabaya

NOTIFIES

Name :

Passport Number :

Flight :

For his / her own need has to bring the following medicines :

No. Items / Kind of Medicines Until Amount

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
34.
35.
36.

Based on medical reason , the above medicines are strictly preferred for daily personal use by the
bearer and this notification is provided to be shown / produced to the Saudi Arabian Authority when
necessary upon arrival for clearance.

Surabaya,
............................

Physician

Tembusan :

1. PPIH Embarkasi Surabaya

2. PT Saudi Arabia Airlines

3. Bea dan Cukai Embarkasi Surabaya