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MARITIME ADMI|{ISTRATOR
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REPIJBLIC ОF ТНЕ MARSHALL ISLANDS
SURNAME
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DATE ОF BIRTH PLACE ОF BIRTH
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M.NTH оо" .// ftБ "r* /f,// CITY Иа-фИ coUNTRY ййдrв Првмдlв
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EXAMINATION IiOR DUTY AS:
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MAILING ДОПdВSS ОF APPLICANT:
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DECK OFFICER п
ENGINEERING oF},ICER п
RADIO OFFICER п
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MEDICдL EXAMINATION 1sBBREvERsEsIDEFoRMEDIсALREQuIREMENTsI STATE DETAILS ONREVERSE SIDE
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RESPIRA}ojЁ GENERAL APPEARANCE
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WITHOUT GLASSES ,i'
WITH GLASSES RT. EAR i! 71,1 LEFT EAR

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дRЕ GLдssEs oR соNтдст LENSES NEcEsSARy то мЕЕт тнЕ REQLцRED vIsIoN sTANDARD? YвsР No П
HEADANDNECK HEART (CARDIOVASCULAф
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IS SPEECH UNINIPAlRED FoR NoRMAL volcE COMMUNIcATloN'l

EXTREМITIES
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IS APPI.ICANT VACCINATED IN ACCORDANCE WITH WHO RECONЛV{ENDATIONS? YBs tЧо П

IS APPLIсANT SI]TFERING FROM ANY DISEASE LIKELY то вЕ АGGraАчАтЕD BY WORKING ABOARD А yPýSEL, oR то RENDER HIN4/HER LINT,IT FоR SER\4CE
АТ SEA OR LIKE]-Y ТО ENDANGER ТНЕ HEALTH ОF OTIIER PERSO1.IS ON BOARD? YBS П t TO И
IF YES. PLEASE ENTER EXPLANATION IN ТНЕ SECTION АТ ТНЕ ВОТТОМ ОF ON РАGЕ 2

NmDIcAтIoNs? YBs П No

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IS APPLICANT TAKING ANY NON,

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THls slGNATLIRE sно6.цr/в nлFl.\ED tN тнЕ pREsE\(T ОF ТНЕ EXAMINING PHYSICIAN

THIS IS ТО CERTIFY ТНАТ А PHYSICAL EXAMINATION WAS GIVEN ТО /)drо'ff /lzuыfuB

NAME оF APPLIсANT (SURNAME, GI\,EN NAME(S))
THIs дррllсдNт Is cERTIFIю FRJiE оF coMMtINIcABLE DIsEAsE (oR vIRusEs гок cooKs): YBs Е tчоП
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П кдоIо оггlсвк / "r_Е6r,
Ш,dлтlл,тс / П CHlBp Соок / П Соок P}tMITHouT дt ту KBsTKtcTtotJs / п
RESTRICTIONS

NAME AND DEGREE ОF PHYSICIAN /fr, lУf*-ilc;:f i::;:1;,,r';1,.,,,

ADDRESS ё* fu|riJi.:lj

NAME ОF PHYSICIAN,S CERTIFICATING Рhопе: +371 1

DATE ОF ISSUE ОF PHYSICIAN,S CERTIFICATE

SIGNATURE ОF PHYSICIAN

This oertifioate is issued Ьу authoriý of the Maritime Adminbtrator md in oomplianoe with the rеquirеmsпЬ of the оп StandardB ofTraining,
Certifioation and Watchkeeping for Seafares 1978, as amende{ and Labour
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