REPUBLIC OF INDONESIA REPUBLIC OF INDONESIA

MINISTRY OF HEALTH MINISTRY OF HEALTH

Regency /Municipal Health Service Regency /Municipal Health Service
of port Health Office Class I of Surabaya of port Health Office Class I of Surabaya

TO WHOM IT MAY CONCERN TO WHOM IT MAY CONCERN

Herewith the undersigned : Herewith the undersigned :
Name : Name :
Occupation :Port Health Medical Officer Occupation :Port Health Medical Officer
Address :Port Health Office Class I of Surabaya Address :Port Health Office Class I of Surabaya

NOTIFIES THAT NOTIFIES THAT

Name : Name :
Passport Number : Passport Number :
Flight : Flight :
For his/her own needs has to bring the following medicines: For his/her own needs has to bring the following medicines:
No. Item/Kind of Medicines Unit Amount No. Item/Kind of Medicines Unit Amount
1.

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

Surabaya, Surabaya,

Physician, Physician,
Name Name