| APPLICATION FOR REVIEW OF: |
| ASSESSMENT |
| *Refuse to issue a Medical Certificate |
| *Impose Restriction on Medical Certificate |
| *Suspend or Cancel Medical Certificate |
| (Delete whichever is inapplicable) |
| I hereby apply for a review of the above decision and request that arrangements be made for me to be examined by an independent medical referee. |
| I agree that a report of my case may be submitted to the medical referee by the recognized duly qualified medical practitioner. |
| I understand that I am entitled to present any medical evidence available to me in support of my case and agree to any medical report prepared by the examining doctor being made available to the medical referee. |
| Signed |
| (Name in block letters) |
| Address |
| Telephone No. |
| NOTE. Before lodging an appeal you are advised to consult your usual medical practitioner and, should you wish to submit medical evidence in support of the appeal, you should arrange for this to be sent to the medical referee before the appointment date. |
| You will be advised of the name and address of the referee and the date for your appointment as soon as this has been arranged. |