Republic of the Philippines

Province of Negros Occidental

Provincial Health Office

Basic Life Support Training

MEDICAL CERTIFICATE

This is to certify that _____________________________________________________________

(Name and Designation)

is physically and medically fit and -

1. has no heart and respiratory problems,

2. not on the “family way” or pregnant (female only), and

3. has no contagious disease.

_______________________________, M..D.
(Signature over printed name)

License No. _________________________

PTR No. __________________________

____________________________, 200___