July 20, 2023

ACKNOWLEDGMENT RECEIPT

Received from the following persons the amounts listed below, representing
full payment for their application in Japan.

Name Address Position Amount

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Received by:

NURUSAFAH A. GATCHALIAN
Agent
Valid ID ____________________

Conforme:

Name Signature Valid ID

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.