ISSUED ON BEHALF OF THE DEPARTMENT OF SHIPPING GOVERNMENT OF THE PEOPLE'S REPUBLIC OF BANGLADESH Farm Msc Sng, OF -@ORS- AFF SEAFARER MEDICAL CERTIFICATE somificate is faved in accordancs with Bangladesh Meschant Shipping Ordioance, 195) and Bangladesh Marchant Shipping ‘Officers and Ratings Training, Certification, Recruitment, Work Hours and Watch ccping Rules, 2011 ia compliance wich the {nsermational Convestion on Scandands of Training Cemificatc and Watch keeping fot Seafarers, 1976 as amended (STCW"7H} aoc | eguiatiog 1.2 of the Mantime Labour Convention, ‘SEAFARER INFORMATION: Name: Last fhe $5 yA Date of Binh ipo/naMrrrry) Gender (Mal Nationality CDC Na. ee Seaman 1B No. ‘Occupation: Deck/Er tering /Other premeemend =~ ahs Maden samen ateae Le Rag BD Fire MOR TER 5 Loe ne Mother's Name: MABEDA ESA Mailing address: House No- Street/Raad Locanevagea SORE 9 PO. PSO mae eet DECLARATION OF THE RECOGNIZED MEDICAL PRACTITIONER: lam duly authorized by the Department af Shipping, Government of the People’s Republic of Bangladesh and confirm the followings; ‘Confirmation that identification documents weye checked at the paint at examination YES/NO Hearing meets the standards in section Avi: YESINO. Unaided hearing satisfactory? YES/No- Visual acuity meets stendards in ection ver Gn Colowe vision meets standards in section Al/9? YES/NO. Date of last coloye vision test: g § HOW 2029 Fit for loakour duties?’ |s the seafarer free from any medical candition likely to be aggravated by service at sea or to render the seafarer unfit for service or to render the health of any other persons on board?- Urisino v 4B. _Any limitations or restrictions on fitewss?- YES/NOF EYES, specify limitations of restritions | Medical/Other > metro 20, Date of examination/issue (oopmmyrvvy).08 NOV 2029 11. Date of expiry (DD/MM/VYYY)....mn. comms "INO MMO than 2 years from the date of examination” “DP NOV 2005 . eee | Thave read the content ef tha cereicate Se aamebeaiomedetitar@tts | 29, io tan en, Taher Cremrer Pre va Alb Eon Ctr {__Seatorers Signature Name & Sygate al tw pce