SURAT KETERANGAN

Nomor :

TO WHOM IT MAY CONCERN

Herewith the undersigned :

Name :
Occupation :
Workplace :

NOTIFIES THAT

Name :
Date of Birth :
Passport Number :
Flight :

For his/her own needs has to bring the following medicines

No. Items/ kind of medicines Unit Amount

Based on medical reasons, the above medicine are strickly 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
clearance.
Padang, ............................................
Physician,

Name : .................................................
Registered Number : ...............................