STATE CERTIFICATE OF GOOD HEALTH

Surname:
_________________________________________________________
Name: ___________________________________________________________
Born in: __________________________________________________________
Date of birth:
______________________________________________________
Current residence:
__________________________________________________
Codice fiscale:
_____________________________________________________
The subject on the basis of the medical examination which was carried out by me, is in good
health and has no any health problems either past or present that wouldnt allow him to practice
of non-competitive sport activities.
This certificate is valid for one year from the date of issue.

Date: ___________________

Stamp
__________________
Signature of doctor