TO WHOM IT MAY CONCERN

Herewith the undersigned

Name : ......................................................................
Address : ......................................................................
NOTIFIES THAT
Name : ......................................................................
Passport Number : ......................................................................
Flight : ......................................................................

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

No Items/kind of medicines Unit Amount

1
2
3
4
5

Based on medical reasons, the above medicines are strictly 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.

Dr. Chairunnisa Burhan

NIPPPK. 197911142023212002
 TO WHOM IT MAY CONCERN
Herewith the undersigned

Name : dr. Chairunnisa Burhan

Address : Puskesmas Bojonggede
NOTIFIES THAT
Name : Sumiyati Asnawi Siung
Passport Number : C 2350625
Flight : 56

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

No Items/kind of medicines Unit Amount

1 Diamicron 45
2 Gliben clamide 40
3
4
5

Based on medical reasons, the above medicines are strictly 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.

Dr. Chairunnisa Burhan

NIPPPK. 197911142023212002