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