REPUBLIK OF INDONESIA

MINISTRY OF HEALTH
Regency / Muncipal 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 THAT

Name :
Passport Number :
Flight :

for his / her own needs has to bring the following medicines
no Items/kind of medicines unit amount
1
2
3
4
5
6
7
8
9
10
11
12
13
15
16
17
18
19
20
21
22
23
24
25

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