REPUBLIC OF INDONESIA

MINISTRY OF HEALTH

Regency/Municipal Health Service

of .............................................

TO WHOM IT MAY
CONCERN

Herewith the undersigned :

Name : dr.

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

dr.

NIP.