Seafarer medical certificate ‘Ministry of Transport, Public Works and Water Management ‘The Kingdom 6f the Netherlands ‘The signing physician declares tn be recogriced bythe Government ofthe Netherlands 362 physician to conduct media! examinations ard ‘to iste medical certificates of fitness for the service on board seaoing’vessls registered inthe Netherlands. « The signing physician declare, tha! the individual cellos to the latect modal criteria ofthe Dutch MManning Regulations for maritime shipping, that he/she is fit for duty, and that his/her presence o board constitutes no unacceptable isk tothe health of others. Data of the seafarer Surman, and itis Place and date of birth Countey of sue and number of soamar's book: Gxamination on tuberculecte ves. date an iy ‘To prevent fraud: dll saatesto be completed cleary in block letters (no deletion)! “The seafarer complies tothe medial standards of Passed Vali dispensation mecica tress YES@" NO = Visual syste: YES or NO - ‘Audttory system: YES or NO 5 ‘ Final judgement medical itnoss Medica fit for seafaring or/as Loak-out or watch duties on the bridge: VES oF NO [ Watch duties in the engine oom: VES or NO i ating without look-out or watch duties: YES OF NO. ‘Area of validity Worldwide Lite 35.2 esl of bsenee of the examination on tubers © Lites oberg nate | = : Period of vality Unt 2 years after the date of sue D Limited, thas Subscription Place and cate of examination Yall unt Signature of physician | Mome stamp of phyician: