Surabaya, January 22th, 2015

TO : VISA SECTION
The Embassy of Australia
Jln H.R. Rasuna Said Kav C 15-16
Jakarta Selatan

Subject : Tourist Visa Application

Dear Sir / Madam,

The undersigned :

Name : Dr. dr. Tahan P Hutapea Sp.P DTCE M.Kes(Ars)

Position : Director of RS Royal Surabaya
Contact : (62) 31 8476111 (ext 1114)

Herewith certify that my employee :

Name : Sari Agustine Lisano

Position : Quality and Patient Safety Head Committee
Passport No. : A 8477979
Contact : (62) 8983191212

This is to certified that Ms Sari Agustine Lisano is a permanent employee in RS Royal

Surabaya, since June 2012 until now and is permitted to take leave to have vacation. She
will be going to Perth, Australia from March 1st - March 4th 2016 for about 4 days.

All the expenses during the trip will be furnishing by her self I will guarantee that she
will not seek any employment or permanent stay in your country and will be return to
Indonesia after the end of the trip and also promise to obey every regulation in your
country.

It will be highly appreciate if you could grant Ms. Sari Agustine Lisano the necessary
visa to enter your country at your earliest convenience.

Thank you very much for your kind attention and good cooperation.

Yours sincerely,

(signature & stamp)

Name
Position