MEDICAL FITNESS CERTIFICATE Ne 004926 ‘Yepaina, Osxecea, 65000 Nezhinskaya street, 37 Medical Centre Hixuucoxa, 37 ‘Odesa, 65000, Ukraine 4380 48 796 15.45 +380 48 796 15 45, ‘odes.med@'gmail.com odes.med@ gmail.com ODESSA MEDICAL License of Ministry of Public Health of Ukraine Nv 183 from 24.01.2020 iyensia Minicmepomea Oxoponu 300p00'n Yipainu.N2183 oid 24 ciwia 2020 poxy ‘This Centre operates'in accordance with the requirement of the Government of Ukraine and the Medical Examination (Seafarers) Convention (ILO N73), as amended by STCW 78/95, Regulation 1/9 and section A-1/9 of the STCW code, and MLC, 2006/2013. In compliance with ILO/WHO/IMO Guidelines for Medical Fitness of seafarers. Lastname First name commen) Ot eau shui wn Date of birth (sara maposrcewna ‘Nationality (rpowaamerso) Meat og [Ba 70 88" 4094 |eikroinion Passport number male Gococp aceon) AP, 66 4 Sob 3 | female O | Position on board\nocaza wa Gopry) Mailing address(aowaums aapeca) Master. (g Motorman 5 Serv. Staff o tess Qiropren Cl 8 aepeaan) s Mtemaraarw] eames" CY fanaa" Ukraine ame clo GS HBsAg —_ NEGATIVE Height Weight Blood pressure | Pulse rate | Respiration uae one (os) (ono (oye) aman opie 445 om|4OO wg 1480/40 monig| 4 inmin AMO Vision Right eye | Left eye Color vision test. Hearit on (oomeon) | (amo) (over erp op (ea) ‘Withhout glasses. Book & Lantern Normal een 40 4.0 ea antp) (dopanaa sce) Sati pigsies Yellow Grom) [Red (sepsonni) (| t eae Green Gen) CY’ Blue Coma) CA] umn | NORMAL.|-SGRMAL Head and neck stremities: Upper Lower | Dental examination Srimocr raat Rrmnserrascws __ Srinoe rasa Sirworr eau | Seaeen NORA ECG ‘Heart, cardiovascular system Stress test X-R xn (cepa copmeceymmmacicen) = NORMAL | (encerer| NORMAL | (Gacpotpegin RAE atitis A Hepatitis B Hepatitis C HIV VDRL (RW) {renamtAY NEGATIVE |p(renanrB) NEGATIVE | (rename) NEGATIVE | (Bly NEGATIVE (PB) rekiive: Blood sugar | Liver fianetionitest “| Kidney funetioniest. | Urine analysis | Stool test (Garam ez mon) trnomsa) ‘Cerin mos) (ssp pa) Bfonsis con (cry rer) NORMAL NORMAL NORMAL NORMAL funormar_|_NoRMAL Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the seafarers ‘te ee or to endanger the health of other eae Nore * a Now ‘ars hon snare am pete arcana pee Stan oe SORE He (she) is found to be fit (not fit) for duty as: 4) — SE ahaa G (Bin na) € mp Gena! 8 ps [ixap Komoxa Name, degree and licensing of Physician: |D (Qs, snipes ra mo inp) HIGHEST CATEGORY DIPLOMA_765172 Date of Issue Glanctereies 25 CAE 9 OBNOL et Declaration of recognized medial practitioner (Woks AE Bol (Uleexapainmnore snp) Ny e ‘9002MEDICAL FITNESS CERTIFICATE Ne 004926 DRUG AND ALCOHOL TEST REPORT “ LTiyersin Minicmepemea Negpesecy sent 37 Oxepu Soopon 8 Viana A183 Oaks 3000, rane * io 4c 205 ana, Onceea, 680 eas 815 5 ODESSA MEDICAL Sint Sic License of Ministry of Public Health of Ulraine N+ 1 from724.01.2020 380 48 796 1945 “an tatapoet Cupane ess ear ota pnp codes med‘agmaicom {rls ee omatn in cman ih he gare fhe ome equation 1/9 snd seeion 81/9 f the STCW code, nd MiG, 2006/2013 alison nes Sater Lastname FE oimme) Fotushunsku Firstname ees) Jeb. Date of birth: — Month Day Year Caaranepeniny wendy, | 00%) 7) | IDL, Passport number Rist twonep menor) 2, 64 ee Lr IMMUNOCHROMATOGRAPHIC METHOD sauyvoxponarocpa il were ofereae ‘Substance ‘evan : Cocaine (ai) GATIVE Marijuana (sapixyana) NEGATIVE Ecstasy (era) NEGATIVE “Amphetamine erin) NEGATIVE Methamphetamine jensen) NEGATIVE Pheneyelidine @emunaiam) NEGATIVE Propoxyphene (povornden) NEGATIVE Benzodiazepine (Gemoaimenis NEGATIVE Methadone (weraon) NEGATIVE ‘Oxycodone (ox NEGATIVE Methaqualone NEGATIVE Opiates (oniarm) NEGATIVE Barbiturates (eptinpa) NEGATIVE Cannabinoids (aves) NEGATIVE NEGATIVE Signature of Tee a) L certify that I am th appears on this ae oe ME Tadao Name, Degree and Licensing 0 (Q's, nina ra ate asap)MEDICAL FITNESS CERTIFICATE Ne 004926 é License of Ministry of Public Health of Ukraine Ne 183 from 24.01.2020 Tiyensin Minicmepemea Oxoporu Bdopos'ss Vxpaliau No183_4id 24 cis 2020 poxy e ‘This Centre in accordance with the requirement of the Government of Ukraine and the Medical ition (Seafarers) Convention (ILO N73), as amended by STCW 78/95, Regulation 1/9 and section A-1/9 of the STCW code, and MLC, 2006/2013. In compliance with IL0/WHO/IMO Guidelines for Medical Fitness of seafarers. Overleaf (opens ix) Declaration of the Recognized Medical Practitioner Yes No (eexapais momar weir satay) (an) ui) Identification documents of applic Laer oxen ani Sep int were checked at the point of examination? upworsaai?) de Is hearing satisfactory/ meets the standards in STCW Code, section A-/9? (Cay wianoinae nop pony A-D9 noaexsy TUB?) v Unaided hearing satisfactory? 7 (Cayx Ges nope sins”) Is speech unimpaired for normal voice communication? i (Guns Ge enti a ony abana enya”) J ‘Visual acuity is satisfactory/ meets standards in STCW Code, section A-1/9? i (oerpora spy sianoniaae erancaprass THB A-19?) Color vision is satisfactory/ meets standards in STCW Code, section A-I/9? mi (Copuiinerss saasopy sianoniae eaitapray TMB AVS?) Date of last color vision test (dayonth yeas) AS O6 ALS (Clara ocrannsoro rey na Ae glasses or contac lenses necessary to meet the required vision standards? - (yp ao cere ia noc chon?) Js applicant vaccinated in accordance with WHO recommendations? ‘Casas vastvoxsunl sav x pexowensanisnn BOO?) k Is applicant taking any non-prescription or prescription medications? mS es Fit for look-out duties? ‘Clpwoarusi oom amie enocrepirata”) Fit for service at sea? sstricti fitness? If yes, pl ify. Serie ee edison ‘(Kowevpi) Signature of App ge aac atmos) PES Confirming that seaarer hasbeen in armed of ‘the paragraph 6 of section 4-1/9 of te STOW, Code Date of Issue y Signature of Physician Camaceressn 06 OF § tage sapYepaina, w.Oneca Meausnnit ueHtp «ODESSA MEDICAL»| Meanuni ornagu nnascknany Ten.: +38948 796 1515 MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD SURNAME: , ‘VEN NAME Pobushynskyt Olek DATE OF BRTH PLAGE OF BIRTH ex pay 7O wont (Up Year FD; ery cobdkraine) rca rumen POSITION ON BOARD: MAILING ADDRESS OF APPLICANT. waster Q Deck orricen a ENGINEERING OFFICER a (Ukraine) RADIO OPERATOR a Ukr: ees B aine DECLARATION OF THE AUTHORIZED PHYSICIAN sion COLOR TEST TYPE HEARING peneerevoee tte nsere het [RIGHT EVE 22 ricHT ear NORMAL Es retour neo UFTEE 40 = terre _NORMAL Confirmation tat Wentcation documents were checked atthe point of examination: VES ELE no Hearing meets the standards in STCW Code, Section A107 YES NOL] __NOTAPLICABLE C] Untied nearing satisfactory? Yes (J No Visual acuity meets standards in STCW Code, Section Aa? YES ZNO Colour vision meets standards in STOW, one ves NOL) (the wsual test His roqured every si Date of heist colour vision £3 106 tlt moe the roquted vision standards? YES C] NO LT no O no 2 's the oafarerfee rom any medical condtion key tobe aggravated by service ai sea ort render the seafarers unfl fr such eervice orto endanger the heath of other persons on board? YES. wo Hereby | deciare that | am in knowledge ofthe contents ofthe Physical Examination. Potushuyasky: Oteh £5. OB ob OtS Snare of Aopen Tae of Ales Oa GIRCLE APPROPIATE CHOICE: (HE J SHE) 18 FOUND TO BE (FIT / NOT FID FOR DUTY AS A (MASTER / DECK OFFCIER /| [ENGINEERING OFFICER / RADIO OPERATOR / RATING) (WITHOUT ANY J WITH THE FOLLOWING) RESTRICTIONS: ‘CATEGORY DIPLOMA 765172Pega MEDICAL CENTRE “ODESSA MEDICAL” TOB - Meqmunnii yextp «Odeca Medixan» RECEIPT CASH ORDER (Keumanujin) PAYER — Potushynskyi Oleh (Qnamuux, REASON - PAYMENT OF MEDICAL EXAMINATION ((idcmaga) - Cnnata mepmunoro ornapy Price. 85 USD (Cyma) - 3000 ep Date -23.06.2023 lama}