MEDICAL EXAMINATION FORM DIENST BESMETTELIJKE ZIEKTEN/

AIDS-info
Avicenastraat 1
Oranjestad
Intended only for DIMAS Tel 5224239/5224241
Fax 582-7352
admindbz@dvg.aw

In connection with the intentions to obtain a residency and/or work permit for the benefit of
the person mentioned below:

To be completed by the applicant:

Lastname:  Male  Female

Name:  Pregnant

Address in Aruba:

Local phonenumber: Email:

Date of Birth: Age: Marital  Single  Divorced

Status:  Married  Widowed  n/a
Nationality: Birthplace:

Documents to be submitted:

Result of medical tests of a medical institution and/or doctor located in Aruba

❑ Anti HIV-test (except children aged 10 years and under, or with Dutch Nationality);
❑ VDRL-test. (except children aged 10 years and under, or with Dutch Nationality);
❑ Hepatitis-B test (all ages except with Dutch Nationality);

❑ Pulmonary X-Ray (except children under the age of 15)

❑ Medical Certificate
❑ Original DIMAS (TATA) document printed in color
❑ Copy of the front page of the passport, copy last arrival date in Aruba and VISA.
In connection with the application submitted for medical advice and if requested by the DBZ, it is required to provide
further information about the state of health of the applicant.

Applicant hereby declares that the information contained in the application form, and in the enclosed documents is true
and undertakes to provide documentary evidence, if required;
This form by the DBZ is not an automatic award of a residence and/or work permit by DIMAS.

Signed, ______________________________ Date_________________________________

Applicant's signature (Adult) date/month/year

In te vullen door DBZ: Naam ambtenaar en

stempel DBZ:
❑ Documenten zijn compleet Datum ontvangst:_____________________

Registratie no.: ________________ Aankomst datum:______________________

______________________
Opmerking(en): _________________________________________________________________