Certificate of Physical Fitness: ( See rule 10 (i) )

Date of examination : ___________________________ Medical Roster No.: ________________________

Name : ___________________________ ____________Registration No.: __________________________

Father’s name : ________________________________ C. D. C. No. : ______________________________

Age : ______________

Identification marks :

1. ______________________________________________

2. ______________________________________________

3. ______________________________________________

Result of the medical examination :

Signature or thumb impression of seaman.:

Office stamp ________________

Date: ____________________

Place _______________________

Signature of the Medical Authority. _______________________