REPUBLIC OF INDONESIA

MINISTRY OF HEALTH
Regency/Municipal Health Service
of
···················· ·· ····························

TO WHOM IT MAY CONCERN

Herewith the undersigned • '--.:, Jo I r--' ~ I

Name , - - YI
Occupation l • ••
Addrefs '"'', •n
NOTIFIES THAT

Name ,-- ,.
Passport Number .1' ~ 1 r,J..,
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for his/her own needs has to bring the following medicines I

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Items/kind of medicines
. ~~

Unit
~
Amount i
I

1. ····· ······· ···················· ··········· ··· ···

2.
3.
4.
5.
6.
7.
8.
9.
10 .

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Based on medical reaso"ns, the above medicines are strictly prepared for daily per-
sonal use by the bearer, and this notification is provided to be: shown/produced tC' the
Saudi Arabian Authority Whennecessary upon arrival for clearance
........................... .. .. ................... , 20 ......
Physician ,
Name
Registered number