9999999.doc
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MEDICAL CERTIFICATE FOR PERSONNEL SERVICE ON BOARD
SURNAME: asq
GIVEN NAME (S):
DATE OF BIRTH:
PLACE OF BIRTH
SEX
DAY
CITY sq
MALE
MONTH
YEAR
POSITION ON BOARD: MASTER DECK OFFICER ENGINEERING OFFICER RADIO OPERATOR RATING
COUNTRY qs
FEMALE
MAILING ADDRESS OF APPLICANT:
DECLARATION OF THE AUTHORIZED PHYSICIAN VISION
COLOR TEST TYPE
WITHOUT GLASSES
WITH GLASSES
RIGHT EYE LEFT EYE
BOOK RIGHT EAR
LANTERN
YELLOW
RED
GREEN
BLUE
Confirmation that identification documents were checked at the point of examination: YES Hearing meets the standards in STCW Code, Section A-1/9? YES Unaided hearing satisfactory? YES
NO
LEFT EAR
NO NOT APLICABLE
NO
Visual acuity meets standards in STCW Code, Section A-1/9? YES
NO
Colour vision meets standards in STCW Code, Section A-1/9? YES (the visual test it is required every six years)
NO
Date of the last colour vision test: (Day/Month/Year)
/ / .
Are glasses or contact lenses necessary to meet the required vision standards? YES Able for watchkeeping? YES
HEARING
NO
NO
Is applicant taking any non-prescription or prescription medications? YES
NO
Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to endanger the health of other persons on board? YES NO Hereby I declare that I am in knowledge of the contents of the Physical Examination.
Signature of Applicant
Name of Applicant
Date
CIRCLE APPROPIATE CHOICE: (HE / SHE) IS FOUND TO BE (FIT / NOT FIT) FOR DUTY AS A (MASTER / DECK OFFCIER / ENGINEERING OFFICER / RADIO OPERATOR / RATING) (WITHOUT ANY / WITH THE FOLLOWING) RESTRICTIONS: NAME AND DEGREE OF PHYSICIAN: ADDRESS: NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY:___________________________________________________________________ DATE OF ISSUE PHYSICIAN’S CERTIFICATE:___________________________________________________________________________
SIGNATURE OF PHYSICIAN:
STAMP OF PHYSICIAN:
PHYSICIAN LICENSE NO. __________________________ EXPIRY DATE OF CERTIFICATE: This certificate is issued in compliance with the requirements of the STCW Convention, 1978, as amended and the Maritime Labour Convention, 2006.
DATE:
SURNAME: asq
GIVEN NAME (S):
DATE OF BIRTH:
PLACE OF BIRTH
SEX
DAY
CITY sq
MALE
MONTH
YEAR
POSITION ON BOARD: MASTER DECK OFFICER ENGINEERING OFFICER RADIO OPERATOR RATING
COUNTRY qs
FEMALE
MAILING ADDRESS OF APPLICANT:
DECLARATION OF THE AUTHORIZED PHYSICIAN VISION
COLOR TEST TYPE
WITHOUT GLASSES
WITH GLASSES
RIGHT EYE LEFT EYE
BOOK RIGHT EAR
LANTERN
YELLOW
RED
GREEN
BLUE
Confirmation that identification documents were checked at the point of examination: YES Hearing meets the standards in STCW Code, Section A-1/9? YES Unaided hearing satisfactory? YES
NO
LEFT EAR
NO NOT APLICABLE
NO
Visual acuity meets standards in STCW Code, Section A-1/9? YES
NO
Colour vision meets standards in STCW Code, Section A-1/9? YES (the visual test it is required every six years)
NO
Date of the last colour vision test: (Day/Month/Year)
/ / .
Are glasses or contact lenses necessary to meet the required vision standards? YES Able for watchkeeping? YES
HEARING
NO
NO
Is applicant taking any non-prescription or prescription medications? YES
NO
Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to endanger the health of other persons on board? YES NO Hereby I declare that I am in knowledge of the contents of the Physical Examination.
Signature of Applicant
Name of Applicant
Date
CIRCLE APPROPIATE CHOICE: (HE / SHE) IS FOUND TO BE (FIT / NOT FIT) FOR DUTY AS A (MASTER / DECK OFFCIER / ENGINEERING OFFICER / RADIO OPERATOR / RATING) (WITHOUT ANY / WITH THE FOLLOWING) RESTRICTIONS: NAME AND DEGREE OF PHYSICIAN: ADDRESS: NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY:___________________________________________________________________ DATE OF ISSUE PHYSICIAN’S CERTIFICATE:___________________________________________________________________________
SIGNATURE OF PHYSICIAN:
STAMP OF PHYSICIAN:
PHYSICIAN LICENSE NO. __________________________ EXPIRY DATE OF CERTIFICATE: This certificate is issued in compliance with the requirements of the STCW Convention, 1978, as amended and the Maritime Labour Convention, 2006.
DATE:
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