PEMERINTAH PROVINSI JAWA TIMUR

DINAS KESEHATAN
RUMAH SAKIT PARU SURABAYA
Jl. Karang Tembok No.39 Telp. (031) 3713836, Fax. (031) 37288920 Surabaya

MEDICAL CERTIFICATE

No :

I, the Undersigned Doctor in Medicine, have examined :

Name : Hartomy Akbar Basory.

Place, date of birth : Sidoarjo, July 07th 1990.

Age : 27 years old.

Nationality : Indonesia.

Height/ weight : 165 cm/ 75 kg.

Blood Type :A+

I have found that Mr. Hartomy Akbar Basory

is in healthy condition after though :

1. The basic medical check up : Fit

2. Diagnosis of HIV/ AIDS : Non Reactive
3. Tuberculosis test : Negative
4. Hepatitis test : Negative

Surabaya, February 5 th 2018.

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*)Copy of laboratory medical check-up result is attached