STATEMENT LETTER

The undersigned below:

Name :
Position :
Company Name :

Hereby declare that we will deliver the following goods for sample only (“Sample”) to PT. ……………..:

Name of Sample :
Quantity of Sample :
Type of Sample :
Serial Number :
Destination Country :
Consignee/Beneficiary :
Invoice Number :
Departure Date :
Arrival Date :
Loading Port :
Unloading Port :

The Sample are required by Ministry of Energy and Mineral Resources to be tested in laboratory by The
Research and Development Centre for Oil and Gas Technology (Lemigas), as one of requirement to
obtain Nomor Pendaftaran Pelumas (NPT), which should be applied by PT. …….. to Directorate General
Oil and Gas – Pelumas or any of its authorized delegation.

In accordance to the abovementioned, we acknowledge that the Sample shall not be used for
commercial purpose or other prohibited activity.

Hereby this statement is made truthfully and to be used accordingly.

Yours Faithfully,

Stamped.

……………………………