MEDICAL CERTIFICATE FOR PERSONNEL ON SERVICE ABOARD

NAME: ____________________________________________________________________________________________________ SURNAME FIRST NAME MIDDLE NAME BIRTH DATE: ___________/_________________________/__________ GENDER Male Female DAY MONTH YEAR POSITION ABOARD: ____________________________________________NATIONALITY:____________________________ ADDRESS:_________________________________________________________________________________________________

I.D. CARD OR PASSPORT Nº: ________________________________________________________________________________

VISION

COLOR PERCEPTION

AUDITION

RIGHT EYE LEFT EYE BOTH EYES

NOT CORRECTED 20/ 20/ 20/

CORRECTED 20/ 20/ 20/

________BOOK ________LANTER YELLOW__________ RED __________ GREEN ___________ BLUE __________

RIGHT EAR ______________ LEFT EAR _______________

DECK SERVICE ENGINE SERVICE SERVICE OF

CAMERA OTHERS SERVICES

APT

NOT APT

W ithout restrictions With restriction Need visual correction: Yes: Not: As a doctor duly authorizes by the Panama Maritime Authority, I have examined the above person, in accordance with the nacional and international standard. Taking in consideration, the physical examination, personal statements of the examined person and the results of the laboratory tess carried out, I DECLARE that he/she is: Apt/ match stand ng Not apt/ match standing Place of physical examination: _______________________________________________________ Name of Clinic

_______________________________________________________ City / Country Physical Examination Date: _____________/_____________/________________ Expiration Date of this Medical Certificate: _____________/_____________/_______________ Not of the Authorized Examining Doctor: _____________________________________________________ Print _____________________________________________ Signature of Examining Doctor Hereby I declare that I am in knowledge of the contents of the Physical Examination carried out: (signature of the examined person):__________________________________________

TIT-F-009 REV 02

Comments of the Medical Record and Physical Exploration

Seal of Examining Doctor

This Certificate, will have a validity of two (2) years from the date of its issue. " STCW 95, rule I/9. Medical standards issue and Registration of Certificates " Resolution JA Nº 009-2001. Chapter XIII Medical standards, Articles 54 –

Medical fitness for seafarers. " ILO / WHO/A.2/1997 – Policies to establish standards of medical fitness for

seafarers previous and within the seagoing service according with the he International Labour Organization (ILO) and the Health World Organization (OMS).

“Resolution ADM -082 -2001, whereby is approved and it published the list of authorized doctors to carry out medical examinations for seafarers and recognized by the Panama Maritime Authority.

Seal Panama Maritime Authority