Latvij as JПras administriicija Maritime Administration of Latvia

JгR\IEKA \lEDICI\ISKAIS SERTIFIMTS Nr.

SEAFARE R,S N4EDICAL CERT] FIсАтЕ No. чс - ?674з

Yards(-i) Uzr,5rds
(Narne(s)) 1Surпаrте)

Parbauditý identifikacijas dokuments: ! pase / ffpe.soo"s aplieclba l f] jПrпiеkа grfrmаtiца Nr. /J lэ

(Identification document checked: passport 7 " identity card / sеаmап', ШrсЬафЬооk' No.) //,l 7;Уr; *''
Dzimýanas datums (Date of birth) 13 _ 06 _ 19Вб Valstspiederlba (Nationality) Dzimums (Gепdеr)
(dd.mm.pyy)
т лтп7т д П \'Trietis П Sieviete
(dd.mm.yyyy) lJýi v J.rt
1Male) (Fепlаlе)

Dzirde atbilst standartiem. kas noteikti STC\\ kodeksa A-I/9 iedala

gд1l\ъs) Пхс (xol
Неагiпg tlreets thc stalrdards irr section A-l,'9 оГSТСW code)

Dzirde bez palTglTclzekliem ir apmierinoýa (Unaidecl hеагiпg satistactory) MJa (Yes) LJ\e (No)
Redzes asums atbilst standartiem, kas noteikti STC\\' kodeksa A-I/9 iedala
(VisLrai act"titv t-tleets statldards in section A-Il'9 of STC'\\ code) ПJa (yes) ПNс (No)

Kr5su redze atbilst standartiem" kas noteikti STC\\'kodeksa A-I/9 iedala

(Ссllоuг r isiotl tl-teets standtiгds in section .\-l 9 оГ STCW code) UJa(Yes) !Хс t\o)

(dd.mm.111r )
КrДsu redzes p€dcjas рДrЬаudеs datums (Date оГthе last соlоltг r ision test)
L/.,/2/.u}/ (dd.mm.yy-ly,)

Bez vesellbas рrоЬlЕmim, kas var saasinities reisa laiki vai kчru dC! jПrnieks var k|iit перiеmёrоts
savu рiепДkumч pildlýanai vai арdrаudёt citu uz kuýa esoýo реrsопu veselibu
(Fгее ftom anv nledical conditiorr likely to Ье aggгavated Ьу service at sea ог to гепdеr the seafher unt'it Гоr
!
т
l ],1.1a (Yes) l lNё (No)
sttch sегr,iсе ог to епdапgег the health оГоthег persons on board)
Nepiecieýams Пetot medikamentuý reisa laika (Needs to take medication during service at sea) ПJа tYes) Пхе txol
PienrOrots(-a) navigitcijas sardzes uп поr,ёrоýапаs pienikumu pildIýanai
(Fit tЬr rravigatitlrlal ri atch and ltlok-out dLrties) Йa\"";l Пiчс (l+о)

Nepiecieýanras brilles vai kontaktlёcaý ( Spectacles оr contact lenses rеquirеd1 LJJa (Yesl lэNс (No)
AtPilst dаrЬаm (перiеmёrоjаmо izsvrtrot) (Fit флdutу within (delete which do not apply)):

ff Urui^komandi
9 (deck department)f]maýTntelpa9К#anda
(епgiп9fерапmепt)
f] cdinaýan2skomandý
{саtу*{gdерагtmепt)
И citý (noradlt)
tother (specitj ))
Czеrr / /цr,r,z_

\ЪsеlIЬаs atbilstlbas iеrоЬеZоjumdрiеmёrаm, Iраýu pieniikurrfu izpilde, kuýoýanas rajons un/r,ai ilgums. kuýa tips)
(Limitations оr restrictiol]s ot-t t-ttness (e.g. specitic duties. trading аrеа апd/ог dr,rration. trpe оГshiр))

ы Nc ! Ja (поrаdтt iеrоЬейоjчmчs)
(No) (Yes (specifl, limitations оr restrictions))

Arstniecltlas iestiides SJ${#jяFajaý рrlшаrаs

nosaukums. adrese. ibБ,, арiз.uреý cetltrý
.-"€-lъ
\Ъsеlllrаs рfl rbaudes datums
LiKBja
fu

t Dпtе ol' he]ltll e\]llliIlat i\)ll )

n-l
LL.
{гl
LL-
ллгl{
LwцL
(dd. m rfi fr iyT Пld m-Й, fr {.у )
kontaktinformicij а
чп oficijilais zlmogý
8ЬтяlЬtl
1 I ssLri п_ч authorit,v's

паmе. address. contact

Sertifi kГrtа derTguma tеrmiпý оо .! о олаэ iпfъгrпаtiоп and
LL. LL. LvL\)
ot}lcial stamp)
(Expirydateofcerlitjcate) (dd.mm.}},}y)(ddmrn.111,y,)

\Ъlsts akcij u sabiedrlbas " Latvijas Jti ras administrEcija" JПrпiеkч

reýistra atzTta jПrпiеkч arsta paraksts uп Zlmogý
Jiirnieka paraksts (Signature and stamp ol'the medical ргасtitiопег recognized Ьу the Registry
(Sеаfhгег's sisпаturе) ol Seatnen of the State stock соmрапу "Магitimе Administration of Latvia")
,? U{.,

.N r%'* ) &,*-
Z.v.

darbl jЕrпiФЪа. Mediclnaýko ýeЁitikatц чаr epýtrтdёt rtbiкoýi пr€iоtrýlо поrmsfiYо ildu pвsibf,m. _ л а tl ( ! "l.'] {58

Medical certificate mау Ье appealed iп ассоrdапсе with the national lефslаtiоп. _ i-l
... '. , : , r {ti
t"i,e
{iпlрt,,з