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REPUBLIC OF INDONESIA

MINISTRY OF HEALTH
Regency/ Municipal Health Service
Of Port Health Office Class I Makassar

TO WHOM IT MAY CONCERN


Herewith the undersigned :
Name :
Occupation :
Address :
NOTIFIES THAT
Name :
Passport Number :
Flight :

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


No. Items/ kind of medicines Unit Amount

Based on medical reasons, the above medicine are strickly prepared 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.

Makassar, ...... August 2017

Physician,
Name : .................................................
Registered Number

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