| Seafarer's Name |
| Seafarer's Number |
| Date of expiry of this Certificate (dd/mm/yyy) |
| This certificate is valid for one year, from date of issue, for seafarers under 18 years of age and for 2 years for seafarers 18 years of age or over. |
| I certify that I have examined the seafarer named above to the Medical and Visual Standards for Seafarers as contained in the Schedules 1 and 3 of the above-named Regulations and have found *him or her fit for seafaring subject to the following restrictions: *Delete as appropriate |
| Restrictions: |
| Official Stamp |
| Signed |
| Name |
| (Recognized duly qualified medical practitioner) |
| Date of Examination (dd/mm/yyyy) |
| The original or certified copy of the physical report must accompany an application for a Seafarers Document/Certificate. A duplicate copy clearly labelled 'certified copy' on its face and initialled by the examining Medical Doctor must be maintained by the applicant as evidence of physical qualification while serving on board a vessel. |