REPUBLIC OF INDONESIA

MINISTRY OF HEALTH

Regency/Municipal Health Service

of Kudus, Jawa Tengah, Indonesia

TO WHOM IT MAY
CONCERN

Herewith the undersigned :

Name :

Address : Indonesia

NOTIFIES THAT

Name :

Passport :
Number

Flight :

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

No. Items/kind of medicines Unit Amount

10

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

ttd

Kloter SOC