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DOH ACCREDITATION NO.a3-014-1820-IVlF-2

MEDICAL CERTIFICATE FOR SERVICE AT SEA

Approved by the Department of Health (DOH)and the Maritime Industry Authority(MARINA)of the
Republic of the Philippines Issued in compliance with SfCW Coni/enfion, 1978 as amended
Section A-l/9 Paragraph 7 and the Maritime Labour Convention,2006
GIVEN NAME: MIDDLE NAME:

MIPARANUM MACHELOU JUGUILON

AGE: DATE OF BIRTH;(MONTH/OAY/YEAR) PUCE OF BIRTH: NATIONALITY:

34 19 JUNE 1986 SANTANDER CEBU FILIPINO

SENDER: MALE
m FEMALE
□ CIVIL STATUS: SINGLE [ [ MARRIEOj"^^ RELIGION:
ROMAN CATHOLIC
ADDRESS:
BUNLAN SANTANDER CEBU
PASSPORT NO:
SIRB:
P7773101A C1297497
POSITION APPLIED FOR: PLEASE SPECIFY: COMPANY:

DECK ENGINE CATERING OTHERS OILER FAIR SHIPPING CORP.

DECLARATION OF THE ALnHORIZED PHYSIQAN
CONRRMATION THAT THE IDENTIFICATION DOCUMENT WERE CHECKED AT THE POINT OF EXAMINATION
YES NO

HEARING MEETS THE STANDARD IN STCW CODE4ECT10N A-l/9? NO

UNAIDED HEARING SATISFACTORY? YES NO

c;
VISUAL ACUITY MEETS STANDARDS IN STCW CODE, SECTION A-l/9?
✓
□
COLOR VISION MEETS STANDARDS IN STCW CODE, SECTION A-l/9? YES NO

DATE OF LAST COLOR VISION TEST: (D»y/Month/Ysar) 26 / FEB / 2020

□
FIT FOR LOOKOUT DUTIES? YES NO

NO LIMITATIONS OR RESTRICTIONS ON FITNESS?

IF "NO" SPECIFY LIMITATIONS OR RESTRiaiONS: RgStlLAR SURVEIICT CE NEEDED

IS APPLICANT SUFFERING FROM ANY MEDICAL CONDITION LIKELY TO BE AGGRAVATED BY SERVICE AT SEA OR TO RENDER THE SEAFARER UNFIT FOR

SUCH SERVICE OR TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD YES | j NO j |

THIS IS TO CERTIFY THAT A MEDICAL AND PHYSICAL EXAMINATION WAS GIVEN TO:

MACHELOU J. MIPARANUM
(NAME OF SEAFARER]

RESULT:

FIT FOR SEA DUTY UNFIT FOR SEA DUTY:

■H □
RAFAE SI, M.D. Lie. No. 85835
NAME AND SIGNATURE OF EXAMINING/AUTHORIIED PHYSICIAN

DATE OF EXAMINATION: (Day/Monlh/Yfor I 26 JUNE 2020

APPROVED BY: j)
20-06260980 RAFAEL Lie. No. 85835
MEDICAL DIRECTOR

•ftt NAME OF ISSUING AUTHORITY: INTERNATIONAL HEALTH SCREENING CORP.

Units 401-402 4th floor Altolia Buiidino, 2100 Madre ignacia Street, Malate, Manila
PHYSICIANS CERTIFYING AUTHORITY: PROFESSIONALREGl/LATION COMMISSION

PHYSICIANS LICENSE NUMBER: Lie. No. 85835

I HAVER^ AND aA^AS INFORMED Of THE CONTENTS OF THE CERTIFICATE AND OF THE RIGHT TO A REVIEW IN ACCORDANCE WITH PARAGRAPH 6 OF
SEcnON^pOFTHEh^CODE:;-• .'
SEAFARER'S f^E AND SIGNATU.RE: .' MACHELOU J. MIPARANUM date: 07JULY2020
; ■' (THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN)
DATE OF ISSUAN'CE^PEME CERTIFICATE: DATE OF EXPIRATION OF PEME CERTIFICATE;
(DAY/MONTHAEARI 07JULY 2020 (DAY/MONTH/YEAR) 26 JUNE 2022
IHSC Form. 005 Rev 00/ 01JUN13