Seafarer Medical Fitness Certificate
Seafarer Information
Full Name
Date of Birth
Nationality
Rank/Position
Seafarer ID No.
Passport No.
Medical Examination Details
Date of Examination
Place of Examination
Medical Practitioner Name
Medical Practitioner License No.
Certification
This is to certify that the above-named seafarer has been examined according to the requirements, and is:
Fit for duty at sea
Unfit for duty at sea
Fit for duty with limitations
If limitations, specify:
Certificate Valid Until
Remarks
Medical Practitioner's Signature
Date
Seal/Stamp