Marine Crew Pre-Employment Health Declaration

Personal Information

Full Name Date of Birth Nationality Passport/Seaman’s Book No. Position Applied For

Have you ever been hospitalized or undergone any surgery?

Yes No

Please provide details if 'Yes' Do you currently take any medication?

Yes No

If 'Yes', specify Do you have any allergies?

Yes No

Specify allergies

Have you ever suffered from any of the following?

Tuberculosis Epilepsy/Seizures Heart Disease Diabetes Hypertension Asthma Hepatitis Mental Illness Other

If 'Other', please specify

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

Do you use any drugs/narcotics?

Yes No

I declare that the above information is true and correct to the best of my knowledge. Signature Date