_______________________________________________________________________
(Seafarer's last name, First name and middle initial) (printed or typed)

_______________________________
discharge book, passport or number of other valid identity document, and type of document)

has been examined by ____________________________
                                    (Name of medical examiner)

and has been found fit for service at sea in the job of: _________________________________
_________________________________________________________________________
_________________________________________________________________________

His/her colour vision has       _____ been checked                  ______ has not been checked.

He/she was found           ______ fit for look-out duty          ______ not fit for look-out duty

__________________________________
(date and place (city and country) of examination)

___________________________________
(signature of the medical examiner)

____________________________________
(serial number of the certificate)

___________________________________

This certificate expires on __________________
                                       (day, month, year)

                                                                              Official stamp:

Name:_____________________________________________________________________
                (Surname)                         (First Name)                      (Middle Name)
Date of Birth: ______________________________________  Male/Female
Place of Birth:________________________________________________
                                     (State/Country)
Home Address:________________________________________
                        ________________________________________
                        ________________________________________
Rank/Rating/Occupation
Passport/CDC/Identity Card No.
Type of Ship (Container/Tanker/Passenger/Other)
Office Address:________________________________________
                        ________________________________________
                        ________________________________________

 1.   Headache severe (one side) (Migraine)                                    ________
 2.   Head injury/concussion                                                            ________
 3.   Eye/Vision problem (Contact Lenses/Glasses)                          ________
 4.   High/Low Blood Pressure                                                        ________
 5.   Ears/Nose/Throat Problems                                                     ________
 6.   Hearing Impairment                                                                  ________
 7.   Asthama/Bronchitis/Sinitus                                                       ________
 8.   Dizziness/ Fainting (loss of consciousness)                                ________
 9.   Epilepsy Seizures                                                                     ________
10.  Heart Condition (Angina)                                                         ________
11.  Rheumatic Fever                                                                      ________
12.  Hay Fever/Allergies                                                                 ________
13.  Skin Problems                                                                         ________
14.  Infections/Contagious Disease                                                  ________
15.  Stomach/Bowel Disorders                                                       ________
16.  Blood Disorders                                                                      ________
17.  Jaundice/Liver Problem                                                            ________
18.  Diabetics                                                                                  ________
19.  Thyroid Problem                                                                    _________
20.  Kidney Problem/Stone in Bladder                                            ________
21.  Hernia/Urinary Disorder                                                          _________
22.  Genitus/Urinary Disorder                                                         ________
23.  Pregnancy/Female Disorders                                                   ________
24.  Sleep Problems                                                                       ________      
25.  Nervous/Mental Illness                                                            ________
26.  Loss of Memory                                                                      ________
27.  Psychiatric Problems                                                                ________
28.  Depression                                                                              ________
29.  Vericose Veins/Piles                                                                ________
30.  Back Injury/Problem/Slip Disc                                                 ________
31.  Fractures/Dislocations                                                              ________
32.  Restricted Mobility (any part)                                                   ________
33.  Amputation (any)                                                                     ________
34.  Smoking/Tobacco Quantity (intake)                                         ________
35.  Alcohol Intake Quantity                                                           ________
(y)   If there is 'Yes' to any of the questions please elaborate in detail - when and
       where treatment followed?  Duration?  Particulars of Doctor who treated.  (For
       additional space use extra sheet).
36.  Are you suffering from any malignancy?                                   ________
37.  Have you ever been signed off as sick or repatriated from
       ship prematurely?                                                                    ________
38.  Have  you ever been hospitalised (any where)?                        ________
39.  Have you ever been declared unfit for sea service?                  ________
40.  Has your medical certificate ever been restricted or revoked?  ________
41.  Are you aware that you have any medical problem, disease
       or illness?                                                                               ________
42.  Do you feel healthy and fit to perform the duties of your
       designated position/occupation?                                              ________
43.  Are you allergic to any medication?                                         ________
(y)   If yes to any of the above questions please elaborate with details as to (y) above
44.  Are you taking any non-prescription medication?                    _________
       If yes, please elaborate the dosage and purpose with details as to (y) above

            I hereby certify that the personal declaration hereabove is a true statement to the best of my knowledge.
Full Name (Block Letter)                                                            Signature
Date:                                   Place:                                              Time:
 
            I hereby authorise the release of all my previous medical records from any health professional, health institution and public authorities who may have dealt with my case to
Dr._______________________(the approved medical examiner of the Company)
Full Name:                                                                                  Signature
Passport/CDC No.
Date                                    Time                                                 Place