‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬

Arrival Registration

Name TUKIYEM KROMOKARSO ‫ﺍﻻﺳﻢ‬

Passport Number C9287023 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1963-07-02 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084400631 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2816015257 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺃﺳﺘﺮﺍﺯﻳﻨﻴﻜﺎ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﺃﻭﻛﺴﻔﻮﺭﺩ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of
Oxford–AstraZeneca Vaccine

First Dose Date 2021-10-01 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-10-29 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-08-10 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name WAGITO REJO ‫ﺍﻻﺳﻢ‬

Passport Number C9864378 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1956-12-31 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084401206 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2899641307 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺑﺎﻳﻮﻧﺘﻚ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﻓﺎﻳﺰﺭ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of Pfizer-BioNTech
Vaccine

First Dose Date 2021-06-09 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-07-08 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-05-11 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name WAGIYO WIYONO ‫ﺍﻻﺳﻢ‬

Passport Number C9864375 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1960-12-31 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084402163 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2819671602 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺑﺎﻳﻮﻧﺘﻚ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﻓﺎﻳﺰﺭ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of Pfizer-BioNTech
Vaccine

First Dose Date 2021-10-13 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-11-11 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-06-25 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name WALIDI DIKROMO ‫ﺍﻻﺳﻢ‬

Passport Number C9864356 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1960-10-20 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084402167 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2874807654 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺃﺳﺘﺮﺍﺯﻳﻨﻴﻜﺎ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﺃﻭﻛﺴﻔﻮﺭﺩ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of
Oxford–AstraZeneca Vaccine

First Dose Date 2021-06-11 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-10-07 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-02-18 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name WARINEM WIYONO ‫ﺍﻻﺳﻢ‬

Passport Number C9865041 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1961-12-31 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084401849 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2816973965 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺃﺳﺘﺮﺍﺯﻳﻨﻴﻜﺎ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﺃﻭﻛﺴﻔﻮﺭﺩ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of
Oxford–AstraZeneca Vaccine

First Dose Date 2021-09-08 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-10-08 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-07-25 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name WARTI JOYO ‫ﺍﻻﺳﻢ‬

Passport Number C9347139 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1953-07-01 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084401928 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2829571721 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺃﺳﺘﺮﺍﺯﻳﻨﻴﻜﺎ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﺃﻭﻛﺴﻔﻮﺭﺩ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of
Oxford–AstraZeneca Vaccine

First Dose Date 2021-04-19 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-05-20 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-08-26 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).
 ‫ﺗﺴﺠﻴﻞ ﺍﻟﻘﺪﻭﻡ‬
Arrival Registration

Name YASIN MASHUDI ‫ﺍﻻﺳﻢ‬

Passport Number C5425867 ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‬

Birthdate 1969-04-18 ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

Visa Number 6084401255 ‫ﺭﻗﻢ ﺍﻟﺘﺄﺷﻴﺮﺓ‬

Nationality Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬

Departure Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺑﻠﺪ ﺍﻟﻤﻐﺎﺩﺭﺓ‬

Registration Number GDP2875710348 ‫ﺭﻗﻢ ﺍﻟﺘﺴﺠﻴﻞ‬

Registration Date 2022-09-28 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺘﺴﺠﻴﻞ‬

Vaccine Country Indonesia ‫ﺍﻧﺪﻭﻧﻴﺴﻴﺎ‬ ‫ﺩﻭﻟﺔ ﺍﻟﺘﺤﺼﻴﻦ‬

‫ﺃﺳﺘﺮﺍﺯﻳﻨﻴﻜﺎ‬-‫ﺟﺮﻋﺘﻴﻦ ﻣﻦ ﻟﻘﺎﺡ ﺳﺎﻳﻨﻮﻓﺎﻙ ﻭﺟﺮﻋﺔ ﻭﺍﺣﺪﺓ ﻣﻦ ﻟﻘﺎﺡ ﺃﻭﻛﺴﻔﻮﺭﺩ‬

Vaccine Type ‫ﻧﻮﻉ ﺍﻟﺘﺤﺼﻴﻦ‬
Two doses of Sinovac Vaccine and one dose of
Oxford–AstraZeneca Vaccine

First Dose Date 2021-03-29 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻷﻭﻟﻰ‬

Second Dose Date 2021-04-26 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻧﻴﺔ‬

Third Dose Date 2022-07-25 ‫ﺗﺎﺭﻳﺦ ﺍﻟﺠﺮﻋﺔ ﺍﻟﺜﺎﻟﺜﺔ‬

Valid Until Date 2022-10-05 ‫ﺻﺎﻟﺢ ﺣﺘﻰ ﺗﺎﺭﻳﺦ‬

‫ ﺃﻗﺮ ﺑﺼﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺪﺧﻠﺔ ﻭﺃﻧﻪ ﺳﻴﺘﻢ ﺍﻟﺘﺤﻘﻖ ﻣﻦ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﻋﻨﺪ ﺍﺻﺪﺍﺭ ﻛﺮﺕ ﺻﻌﻮﺩ ﺍﻟﻄﺎﺋﺮﺓ ﻭﻓﻲ ﻣﻨﺎﻓﺬ ﺍﻟﺪﺧﻮﻝ ﻭﻋﺪﻡ ﺍﻻﻟﺘﺰﺍﻡ ﺑﻬﺬﻩ ﺍﻻﺷﺘﺮﺍﻃﺎﺕ ﺗﺠﻌﻠﻨﻲ ﻋﺮﺿﻪ‬-
.‫ﻟﻤﻨﻊ ﺍﻟﺪﺧﻮﻝ ﺍﻟﻰ ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻌﺮﺑﻴﺔ ﺍﻟﺴﻌﻮﺩﻳﺔ ﻭﺍﻟﺘﺒﻌﺎﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ‬

.(‫ ﻳﺸﺘﺮﻁ ﺣﻤﻞ ﺷﻬﺎﺩﺓ ﻭﺭﻗﻴﺔ ﻣﻌﺘﻤﺪﺓ ﻹﺛﺒﺎﺕ ﺃﺧﺬ ﺍﻟﻠﻘﺎﺡ ﻣﺼﺪﻗﺔ ﻣﻦ ﺍﻟﺠﻬﺎﺕ ﺍﻟﺼﺤﻴﺔ ﺍﻟﺮﺳﻤﻴﺔ ﻓﻲ ﺑﻼﺩ ﺍﻟﻤﺴﺎﻓﺮﻳﻦ ﺍﻟﻘﺎﺩﻣﻴﻦ )ﻭﺯﺍﺭﺓ ﺍﻟﺼﺤﺔ ﺍﻭ ﺟﻬﺔ ﺻﺤﻴﺔ ﻣﺨﻮﻟﺔ‬-

- I acknowledge that the entered information is correct and that the information will be verified when the boarding pass is issued and at the ports
of entry, and the failure to comply with these requirements makes me open to preventing entry to the Kingdom of Saudi Arabia and the legal

- It is required to carry an approved paper certificate to prove the vaccination, certified by the official health authorities in the countries of arriving
travelers (the Ministry of Health or an authorized health authority).