KERAJAAN MALAYSIA

GOVERNMENT OF MALAYSIA
Marine Headquarters, Malaysia Marine Department, P.O Box 12, 42007 Pan Klang
Tel: 63- 3346 7777, Fax: 03- 3168 5289, E-nail:
kpgramarine.gov.my , Website: htip/www.marine gov.my
SIJIL PEMERIKSAAN PERUBATAN
MEDICAL EXAMINATION CERTIFICATE
I) Nama pemegumg sijil (seperti Family Neme Given Nemefs)
dalam passport E
Nume of holder of Certifeate (as in passport):
2) *Jantina: Lelaki /Warita 3)
Gender: Male / Fenmale Warganegara
LtoNARD0 4)
JoHN
No. Kad Pelaut:
CASELY
Nationality. Seafurer Card Na.
5) No Kad Pengenalan Passport:
ldentiy Card No Passport: 98164-13 6o5/ 6) Tarikh Lahir (dd/mm'yyyy)
Date of Birth:
7) Jawatan
Prafession:
8) Pengakuan oleh Pengamal Perubatan yang Diiktiraf:
Declaration of the Recognized Medical Practitioner:
8.1 Pengesaban dokunen pengenalan telah disemak ketika pemeriksaan: Yes/Ya No Tidak
Contirmtion that identifcation ducuments were checked t the point of
examination.
82 Pendengaran menepati piawaan mengikut seksyen A-[9
Hearing meets the standards in sectionA-I9 of the STCWKomvensyen STCW 78 seperti dipinda
78 as amended
8.3 Perdengaran memuaskan tanpa apa-apa barntuan?
U'natded hearing satisfaetory?
84 Ketajaman pengiihatan menepati piawaian mengikut scksyen A-L9
Konvensyen STCW 78 seperti dip1nda?
Visnal acuity meerS Stondurds tH section A-12 of the STCW 78 as amended'

85 Penglihatan wurna menepatipiawaian mengikut seksyen A-\/9

Colour Pisan eets standards in seeon AI9 of the STCW Konvensyen
as qmended?
STCW 78 seperti dipunda
Tarikh terakhir ujian penglihatan warna:
Date of last cuur vision test:

86 Layak untuk tgas

31E/4
panimynuan?
FR for lok-oet diuies

K7 Tiada lhad abau skatan dari spek

kucergasan
Ne Lsmitations or estrictit on frtes
Jikn idk yakakin had daa sekatan

K Adakah pelautbebs datt sp-sp kaduan perhatan yang inkut iniuhntat lali
li buleh iihabkas sseang piaut idak lavak antok pshiditaka
ihahayakanasikitan nns orng di sts kapal? perdilnatat sodeakian stau Rngkin