HEALTH FORM

Dr.(first name, last name)

Zora Vadnjal - Gruden, dr.med.

Born (city) Ljubljana On (dd/mm/yyyy) 21/03/1958

Prov.

Country Slovenija

With office at (complete address) Ambulanta, kofjeloka 6, 4000 Kranj Phone n 04 2065349 Fax 04 2065757

Declare myself fully responsabile and acnkowledge the consequences for falsely declaring that Mr. (first name, last name) Milan Jeler Born (city) Kranj On (dd/mm/yyyy) 03/09/1968 And resident at (complete address) Visoko 46,4212 Visoko With the following disability (if applicable) none Based on a sport physical exam done by me on 11/05/2011 is in good health and fit to compete in a 100 km ultra marathon according to the current laws. This certificate is valid one year from this date. In Date Physicians signature 13/05/2011 Prov. Country Slovenija