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CLIENT INFORMATION SHEEET

1 Company Name PT. MITRA MEDICA SEJAHTERA


Business Address Jl. Pangeran Santri no. 62, Sumedang
Phone Number (0261) 208996
Email ptmitramedicasejahtera@grnail.com
2 Represented By Dra.Hj.Winny Noviyanti
Country Of Birth Indonesia
Date Of Birth 27 – 11-1965
Cityzenship Indonesia
Mobile 081320704353
3 Bank Coordinates PT. BANK RAKYAT INDONESIA
Kantor Cabang Sumedang
Bank Address Jl. Prabu Geusan Ulun No. 137 Kota Kulon
Kec. Sumedang Selatan Kabupaten
Sumedang 45323 Tlp. 0261 201395
Bank Account Name PT. MITRA MEDICA SEJAHTERA
Bank Account No. 009401001613300
Bank Swift Code BRINIDJA
Bank Officer Handi Apriyanto

Phone Number (0261) 201556


Email apriyanto.handi@corp.bri.co.id

Declaration : I hereby swear under penalty of perjury, that the information provided is
both true and accurate. Iam the signatory on the aforementioned bank account all monies
engaged in this account are derived from non- criminal origin : and, are good, clean and
cleared. The funds are in compliance with anti-money-laundering police as set fort by
the Financial Action Task Force (FATF).

Sincerely yours,

Dra.Hj. Winny Noviyanti


Managing Director

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