Mh sass PT Fresenius Kabi Indonesia ‘Menara Bidakara I, 19th Floor Jakarta, 29 April 2019 “J Jend. GatotSubroto Kav. 7573 Menteng Dalam, Tebet Jakarta Selatan 12870, Indonesia Phone: 62 21 8379 Fax +62 218379 3264 TO WHOM IT MAY CONCERN Re: Certificate of Origin The undersigned, duly authorized by the company, confirmed that the below mentioned goods (SYRINGE PUMP TIVA) has been produced or manufactured in Fresenius Vial S.A.S. Le Grand Chemin 38590 Brezins, France No Name of Items Article Number | Serial Number | Quantity 1._| SYRINGE PUMP TIVA 2018290 23520872 1 [2 )SYRINGE PUMP TIVA. 2018290 23520: 1 — ._| SYRINGE PUMP TIVA 2018290 23520878 1 4._[ SYRINGE PUMP TIVA 2018290 23520871 1 5._| SYRINGE PUMP TIVA 2018290 23520879 1 Country of origin : France Country of destination indonesia Distributor PT. INTISUMBER HASTL SEMPURNA On behall of. PT. Fresenius Kabi Indonesia Vice President Medical Device & ENth FRESENIUS KABI Jakarta, 29 April 2019 TO WHOM IT MAY CONCERN Re: Certificate of Origin PT Fresenius Kabi Indonesia Monara Bidakara 18th Floo Ji. Jend, Gatot Subroto Ka Menteng Dalam, Tebet Jakarta Selatan 12870, indonesia Phone: + 62 218379 2363 Fax :+62.218379 2364 The undersigned, duly authorized by the company, confirmed that the below mentioned goods (SYRINGE PUMP AGILIA ID) has been produced or manufactured in Fresenius Vial S.A.S. Le Grand Chemin 38590 Brezins, , France. N _Name of Items Article Number | Serial Number | Quantity _| 7 _ |. TSYRINGE PUMP AGILIATD | _z018094 | 23227485 | 2. | SYRINGE PUMP AGILIA ID 7018094 23227486 1 3._| SYRINGE PUMP AGILIA ID 2018094 23227487 1 ‘4. | SYRINGE PUMP AGILIA ID 2018094 23227488 1 5._| SYRINGE PUMP AGILIA ID | z018094 23227489 1 6._| SYRINGE PUMP AGILIA ID | zore094 23227490 1 7._| SYRINGE PUMP AGILIA ID 2018094 23227494 1 8._| SYRINGE PUMP AGILIA ID 2018094. 23227615 1 RINGE PUMP AGILIA ID. 616 10. | SYRINGE PUMP AGILIA ID 2018094 23227617 1 [A TSYRINGE PUMPAGILIAID_|"_zo1go94___|-_23227618 [a id Country of origin : France Country of destination Distributor Vice President Medical Device & EN : Indonesia : PT. INTISUMBER HASIL SEMPURNAMaton diate untuedibuatkan coo Sanit Spring Pamp Ti Paltarterlapin 10-Apr-19 BRR ROESHA, SUD SYRINGE POMP TVA BH ‘SRNOE POMP AGE [DBE das 11 unit Syringe Pump Aglia untuk DR. RL KOBSMA, RSUD 23520873] 732520872] 729520879| BaTas| 23077887 2322789 25227490 23227408 723227616] 23227617 22227613| NIKMI03191675 Faktur Pajak : 020.001.19.02977732 Tal : 30-03-2019 TIM PEMEGANG KAS RSUD DR.R.I RSUD Karmen DR.R.KOESMA KAB.TUZAN | (CINST.FA 1) JL.WAHIDIN Ji. Karangmenjangan 14C-D JL. DR. WAHIDIN SUDIROHUSODO SUDIRO! 800 - ‘Surabaya NO.800, SIDOREJO TUBAN ‘Surabaya 60225 TUBAN | \ 7:031-5043703, 5043099 00.035,562.8-648.000 0356-321010 13808 | | | | | SYRINGE PUMP TIVA BH | | 1 23520872 UNIT 12,000,000 0.00 0.00 ~—12,000,000 2 23520873 UNIT 12,000,000 0.00 0.00 —_—_12,000,000 3 23520878 UNIT 12,000,000 0.00 0.00 + —_—12,000,000 4 23520871 UNIT 12,000,000 0.00 0.00 —12,000,000 5 23520879 | UNIT 12,000,000 0.00 0.00 —_—12,000,000 | | | | Enam Puluh Juta Rupiah | 60,000,000 AKS-P1903-1471909, NDC \ PSKMJ03190658 54,545,455 REK TRANSFER : PT. IMBER HASII RNA | 5,454,545 BCA HR. MUHAMMAD - SBY , A/C 8290561389 | 60,000,000 VA BCA : 0744100813808 | | SKM) -04-2019 2:57 Hal: 1 of 2Karmen JI. Karangmenjangan 14C-D T:031-5043703, 5043099 PONauUBYNH 5 11 SYRINGE PUMP AGILLIA ( ID ) BH 23227485 23227486 23227487 23227488 23227489 23227490 23227494 23227615, 23227616 23227617 23227618 Faktur Pajak : 00.035,562.8- Seratus Dua Puluh Tiga Juta Tiga Ratus Sepuluh Ribu Rupiah AKS-P1903-1471271 PSKMJ04190201 REK TRANSFER : PT.INTISUMBER HASILSE BCA HR. MUHAMMAD - SBY , A/C 8290561: VA BCA : 0744100813808 020.001.19.02971 TIM PEMEGANG KAS RSUD DR.R.KOESMA KAB.TUBAN JL. DR. WAHIDIN SUDIROHUSOI NO.800, SIDOREIO TUBAN .000 NJKMJ04190515 CSKM) 2: pat DO eta rfp de Su 5 7-04-2018 Tal : 10-04-2019 DR.R.KOESMA RSUD (INST.F: 1) JL.WAHIDIN SUDIROH! 800 - TUBAN 0356-321010 c13808 | | | | | | 11,210,000 0.00 0.00 —11,210,000 11,210,000 0.00 0.00 ~—_11,210,000 11,210,000 0.00 0.00 11,210,000 11,210,000 0.00 0.00 ~—_11,210,000 11,210,000 0.00 © 0.00 ~—_11,210,000 11,210,000 0.00 0.00 + —11,210,000 11,210,000 0.00 0.00 —11,210,000 11,210,000 0.00 0.00 —‘11,210,000 11,210,000 0.00 0.00 ~—11,210,000 11,210,000 0.00 0.00 —11,210,000 11,210,000 0.00 0.00 ~—11,210,000 | 123,310,000 | | 112,100,000 | 11,210,000 | 123,310,000 | 12:49 Hal: 1of1