- 06 / July / 1983 (ad rnen/yyvy) Passport #: € 7151602 Capacity in which the seafaer willserve onboard: Deck (1 Engine (I Hotel ¥ | confirm that | checked and verified the identification document (Passport):vesV NoC] Does the seafarer’s hearing meetsSTCW Code section A-/9? Yes Y NoD Is unaided hearing satisfactory? yes¥ NoO Vision acuity meets STCW Code section A-1/92¥es V_ No Color vision meets STCW Code section A-1/9? Yes¥ NoO : Date of ast color vision test? (dd/mm/yy) 18/ June / 2021 isthe seafarer it for lookout duties?¥es V NoO | Fit for Safety Function(s)? Yes¥ No Fit for other work on boardves V NoO Fit for service without limitations or restrictions? Yes¥ No If ‘No’ please specify: isthe seafarer fee from any medical condition likely tobe aggravated by service at sea or render the _Scatrerunit for such service ot endanger the heath of thers onboard? Yes No) Name of Seafarer Doctor: De RUDY KASTONO Seafarers doctors phone number: 462024 8297255 / 83791386 __ “na ‘seafarer’s doctors address: ASSAADAH MEDICAL CENTRE JL. TEBET TIMUR DLM RAYA NO: 58 | JAKARTA INDONESIA. ‘Stamp Date of Examination (dd/mm/yyyv) 18 / June / 2021 ‘The certificate is valid until(dd/mm/yyyy) 18 / June / 2023 Physician's Name: Dr. RUDY KASTONO|//) [fntins, * ¢ a f bE “We av V ‘CONFIDENTIAL MEDICAL INFORMATION FOR DOCTOR'S USE ONLY i 1 aDENTAL CLEARANCE [ First @ Last ALFA REZIVANSYAR Date: an Name Date of Birth: | 06 July 1983 Nationality: | INDONESIAN Dental History Date of last dental cleaning (dd/mm/yyyv) Date of last dental work (dd/mm/yyvy) Yes No History of > Fixed Bridge (Year. Removable Bridge (Year - Denture (Year + _Implant (ear ) ‘Gums / Gingiva bleeding Treatment Tooth Description (Filling / Crown / Extraction, etc) 10,11, 21,23 | MISSING Follow up required: | ¥/N Fit for duty: Y/N ‘Comments: Name of | Drg.Syaiful Ali Yusren treating Dentist: Signature LF 2 2 sii i ia ‘STAMP ot QQHeIG00 00600G) 7 n ae weaRUORY VP ORTH TZ Winrar CONFIDENTIAL MEDICAL INFORMATION FOR DOCTOR'S USE ONLY