MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD

SUR}{AME: GIVENNÂME {S):

PLÂCE OF BIRTH SEX

DATE OF BIRTH:
DAY MONTH YÉAR CITY COUNTRY MALEI FE}úALEII

PQ§ITION ON BOARD: MAILING ADDRESS OF APPLICANT:

MASTER tr
DECK OFFICER n
ENGINEERING OFFICER u
RADIOOPERATOR ü
RATING n
DECLARATION OF THE AUTTIORIZED PHYSIGIAI{
vtsroN COLOR TÊST TYPE HEAFIING

WITI{OUTGLASSES wlTH GLA§SES ü BOOK

RIGHT EYE n I.ANTERN RIGHT EÀR

YELLOW _ RED
LEFT EYE GREEN BLUE ** LEFT EAR -
-
NO fl
Cqnfirmation that identification doarments \Âêre checked at the point of examination: YES ü
Hearing mêêts the standards in §TCW Code, §ection A-119? YES n No il NOT ÂPLICÁBLE fI
Unaided hearing mtisfadoqf YES E NO n
Msualacuityrnêêtsstandardsin§TCWCode,Sec*ionA-'t/9.2 Ü YES NO E
Colour vision meets standards in STSW Gst e, §ection 4.1n9? YE§ fl Nç f]
(the visual test it is íequited every six yeats)
Date oÍthe last colour vision test (Day/MonttúYear) I I
Âre qtasses or contact lerces nêcessary to Íneet the Íequiled vi§on slândârds? YES E No n
Ableforwatctrkeepíng?YE§ fl NCI n
ls applicant taking any non-prescription oÍ prescription medications? YE§ E NO n
ls the seaÍarer ftee trom any medical condiüon likely to be ággravated by sên icê at sa or to Íendêr ttts seaÚarerc unfit íor §uch §eruice or to
endánger the heâlth of othar persons on board? YE§ ÜNCI f]
Hereby I dedare that I am in knoudedge ofthe contents ofthe Physical Examination.

x
$iunaturê of Applicant Narne uf Applicaú Dâtê

CIRCLE APPROPIATE CHOICE: THE / SHE) IS FOUND TO BÉ (FIT NOT FIO FOR DUTY A§ A (MÀSTER / DECK OFFCIER I
'
ENGINEÊRING OFFICER / RADIO CIPERATOR I RATING) (WÍHOUT AI'IY / WITH THE FOLLOIA'ING) RE§TRIÇTIONS:

NAME AND DEGREE OF

NAME OF PHYSICIAN'§ CERTIFICATING

DATE OF l§§UE PHYSIÇI,AN§ CERTIFIGATE

SIGNATURE OF PHYSICIAN: STAMP OF DATE:-

I
EXPIRY DATE OF CERTIFICATE:
This certiJicale is iswed in compliance wiíh the requÍrements
of the SICW Convention, 1978, as aryrcndqstdlle Àlafittme lilboul Convention 2446.