PASSPORT : C5498137 HOME ADDRESS : JL. BROMO 98-100 RT011/RW005 KEPANJEN, MALANG REGION, EAST JAVA 65163 PHONE : +6282234033010 NAME OF COMPANY : SPECIAL SURGERY HOSPITAL HASTA HUSADA KEPANJEN WORKING POSITION : DOCTOR COMPANY ADDRESS : JL. BROMO 100 KEPANJEN, MALANG REGION, EAST JAVA 65163 COMPANY PHONE : 0341-399499 VISIT RUSIA BEFORE : NO NOTE : NORMAL PROCESS DATE OF TRIP : 31 MARCH 2020 NAME OF TL : BAYU