Medical Fifness Certifi cate

Medicql Examinal¡otts conducte.t ¡ñ accodance with ILO/VHO Guidel¡nes fot con.lucting pre-sea and periodic t{edical Fittlest
gx¿minaliottsfot seafa.e'J. Medical Ceúirtcate ksked ünde, the ptuvisions of the the Intetnatio\al Coneentio4
on Standdúr ol Ttün¡ng,
Certification and Walchkeepinglot Sedfarut (STCH), 1978,as ame ded and the ¡rfairime Lohow Convention (MLC,2006) of ILO.
Aulhotizing aulho¡iq:
Seafarer lnformat¡on
Name (lsst first, middle):
Date o f birth (day/month,/year): Nationality: 4 c Lv.a ?o -L¿ ,'\''
Home address: Ao Í)A D {1:
Passport No-/ Seaman's Book No. or other relwant identity document No.: Cd? )

Declaration of the recoqnized medical pr¿ctit¡oner

Sight
Visual acuity is salisfactory/ meets sta¡dards in STCW Code, section A-V9? (see page 2) v*sGa
Colour vision is sa¡isfacüory/ meets standa¡ds in STCW Code, section A-I/9?(see page 2) Yes El No fl
"'*iilí--l¡-, {,.'f-,j.-fl t
(tesüng only r€quired every slx yearsl o
b",l it iiiüiá",
Haaring
Hc¿¡ing is satisfactory/ mects the stsndards in STCW C.ode, secüo¡ A-V9: ,"" nlG o
Unaided

On tl¡e bs.is of tlre e¡r¡mince's pe¡sor¡l decla¡*io¡, my clioical examination ünd the diagmstic t¿sl r6ults r€cord€d above, I declae the
cx¡qife¿ medicálly:
EfFil for look-oul dufy n Not fit for look-out duty

Other-rerYic€
ú
n
Yrs Ü NoD
Describ€ rstrictions (e.9., speciEc positioq type ofship, trade area, other restrictions):

othcr pcrso¡s on boq¡d?: Yes ! No Út /

ccrtficale isÉue
la !5 39 13
d'le (dayh,ont e".1, Reclros

EDICINA
Certihcate expiry date (¿ry.-tr,ry"n1,1-jJ J5¡ l! lY
589
Sigüh¡¡g rd stsd|p of a¡¡thorised n¡edic¡l p¡¿ctitione¡:

Name and ol[cial st¿mp ofmedical practitionec's certilicating auüority:

\¡i t)¡ l,a p/}O(sc.^r'¡-,L/N}|¿,¿ Jx/P*t

Date of issuc and numb€r ofPhysician's o9
Nsme of su$oris€d tnedical pracÉitioner: ,,,11^4ñ.ro L44Co('¡<, d-)-J.o S
,qddrsss: /¿{ y'¡-^t} AVti ua *--

Co,úrnhg úd th. t.@tt lzt be¿ ¡tdot¡t dof ¡a caí¿rrr olíc cattfcar¿ atd oÍ t righ¡ to a reele* irl a.cord@rcc *ith pragtqt ó {vaion 1-Ú9 qltlt
STCtf Cda

Issue Dat€: l9.l1.2012 Ve¡sion: 1.0 Psge I