MINISTRY OF ECONOMY AND SUSTAINABLE

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DEVELOPMENT OF GEORGIA
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MARITIME TRANSPORT AGENCY
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SEAFARER MEDICAL CERTIFICATE

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SumameJo3::,('()o: JName/1.l:ib:i~o: ID N°/ Jo(:,::,<l:)o No: Seafarer No/ O:J'b~3~ (t)ollNo:

TAVARTKILADZE ITORNIKE 61001076737 1601010087
Date and Place of Birth / w:il'>l>Q.>:Jt'>Ob ffi.)M0\!20 <l:)I> :iwe,o~o: Nationality/ fJMd:i~:id:JMt'>::,: Gender/ l~ho:
14/07/1997 GEORGIA,BATUMI GEORGIAN 0 Male / iJ.)()f,,
Dav/ Month / Year - <'>oob:io / oi:i~ / \'irt(!"IO Country, Citv / ~~~4.16.\, ~.\(!".)~o DFemale/ a ~.
ID checked at the point of examination/ l')l>8MJ3~:i3oll <J?MMU 'il:)8f'l\,8Q.>1> JoM:i<J?f'll'>oll 8M\,8Ml'>:i 0 Yes/ <J?<):ib O No/ ::,fo
Position on Board Vessel/ l'>:)8'b:J <J?•\P3:Jl'>'CJ~O m:i61>8<J?:Jl'>f'll'>:i: Actual Address / czprl{~O'CJMO fJoll.xJ::,t:Jmo:
!i::,3:ibo(') m:ifo'il:Jilv:J 500 t:Je, OMfo <J?::, 8:ioo/500 GT and more 3RD GEORGIA.BA TUMI,GORGILADZE STR.5
OFFICER
SEAFARER MEDICAL EXAMINATION RESULTS/ 8:J'bl:!3:i'C]Mob ll:iaowooo6M ~8MJ3~03oll 'il:J<P:Jl'>:Jl'>o
VISION ACUITY/ 8b:J<;p3:J~Ml'>oll bo8::,b~o<::'.'o COLOR TEST I £3:Jr:,m::, ::,1!!38::, HEARING / ~':"1Mm:ill8nfo
Unaided
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Aided 8:iJMM:Jl'>· 0 BOOK I voc>6o RIGHT EAR/ 8~:Jfo !f~MO
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I
LANTERN/cl~dRMc;pO<::>:Ji'>O
RIGHT EYE
20/20 - Yellow 8300>:J<::'O LEFT EAR/ 8::,t:Job:Jfo tj';'.'.JMO
D:iMX3:Jfo m3::,<::'.'o Red VOO>:J<::'0
LEFT EYE Green avs:i6a 6M
20/20 -
8:iMob:Jfo m3::,<::'.'o Blue <::''JM:X.O
BLOOD TYPE A(II)RH+ EYE COLOR HEIGHT(cm) 188
HAZEL
llobb~ob Xl'>'CJCZJO m3:i<::'.'ob £3:JMO boa:il!!<::'.':J (bcl)
WEIGHT (kg) Body Mass Index
80 22.6
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Visual acuity meets standards in STCW Code, Section A-1/9?
8b:J<;p3:J<::'.'(')i'>::, .:,38.:>tj(')CZJO~:Ji'>b STCW JM<;p:J3lloll A-I/9 fo\,o~ob
0Yes/q:JO::,b 0
Unaided / o:r.:io:iM~:Ji'>:J<::>n o,3::,<::100>
ll1'l:i6co.:>Mc'lni'>b? Aided / cbJ!'lM:)()OM:Ji'>:J<::>O b:io•:·P<::>:JOOO>
Color vision meets the standards in STCW Code, Section A-I/9? @Yes/q:io~b 14/03/2023
CZ3:JMm::, .:>1!!38.:, .:,,38.:>tj(')CZJO~:Ji'>b STCW JM<;p:J3bob A-I/9 fovo<::'.'ob
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Hearing meets the standards in STCW code, section A-1/9?

tt'CJMm.:>llclofo ::,38:ittC'lCZJO~Di'>b STCW J(')<;pD3llob A-I/9 fovo<::'.'ob llo.:>6<;p~MQb? @Yes/ c;po~b 0No/~M~
Unaided hearing satisfactory?
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Fit for Look-Out duties? cl:J-::Jd<::>o~ ~V~M8!'l!'lb b~fo30 0~oo!'l 8:Joi3~<::'8-::JM:J!'l<'.>~ (vo6il~tJ~M:Ji'>:J<::>n)?
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0 Yes/ c;po~b 0No/ .'.>M.'.>
Is the seafarer free from any disease likely to be aggravated by service at sea or to render the seafarer
unfit for such service or to endanger the health and safety of other person~ on·board? 0Yes/,;,pO.">b 0No/.'.>fo
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\1f No. m•k• explanation on back p•g•/ ::J->M<J"l'llomo J>b:,bolJ oo8m~>oo 0».iomom 7,>68>0>1'.)o&> ::JJ,>6> il:JOMl!,l'llO)

AS A RESULT OF EXAMINATION, I DECLARE THAT SEAFARER/e,:i8C'lJ3~:J30b O:J<PDl'>.:>CJ?, 3.:>ob.:><;pQl'>, MM!:l 0:J't\!!3::,'Clr:,o

FOUND TO BE @FIT/ 0 NOT FIT
TO PERFORM FUNCTIONS APPROPRIATE TO THE POSITION 1T 1
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 Limitations or restrictions on fitness?
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Restrictions (if any)/ cl:J'b~·,'.N?3:Jl)o (:iMll:JDMDoll 'cl:Jflmb303;~'clo):

Name of Medical Practitioner:

Date of Examination:
':'.l'B~:Jl'>."l8<'1bo~ :Jdo8oll ll;,b:J~, o· 14/03/2023
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Signature and Stamp of Medical Pract' @ er: ,fJ,;'1J3
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Expiry Date: 13/03/2025
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I am in knowledge of the content of th of the right to a review in accordance with legislation
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Name of Seafarer:
TORNIKE ConfinnbyS;g"'"''"
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TAVARTKILADZE 3:iq,:ibo<JM:Jl'> ti 0~a(')voMom:

Date / o,;,<ryo o: 14/03/2023

ADDITIONAL INFORMATION/ q,:ia:ioo()oo,o 06"23MM8."l<30:i
Is the seafarer suffering from communicable disease?
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Is seafarer vaccinated in accordance with WHO recommendations?
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If yes, please indicate the date/ ao'C)O)OO)OO) O).)MOl!?O (w:iwo()oo,o 3:illjbob O:J8mb303:iclo :
Is the seafarer able to demonstrate adequate speech to communicate effectively?
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Is seafarer taking any non-prescription or prescription medications?
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If yes, please indicate the name of medications. 80j0JCJCJJOOJ 8:Jc;t>OJ."l8:J6oo (w:iwo5omo 3:ibjbob clo8mb303:iclo)

ANY ALLERGIES OR OTHER VITAL INFORMATION

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ADDITIONAL COMMENTS OF DOCTOR I odo8ob c;t>:iB:io:J()omo 00600360()0:

Name of Medical Centre:

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Stamp of Medical Centre:

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. .. . 1 Convention on STCW 1978, as amended,

This Medical Certificate has been issued in accordance Mth the provJSJons of the lnremauona fi:xlnb o:;wb:JI>" 1979 (j~
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