| Date of application:
Дата подачи заявления:
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Last Name:
Фамилия:
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Other Names:
Другие имена:
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Date of Birth:
Дата Рождения:
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Place of Birth:
Место Рождения:
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Sex: (Male/ Female)
Пол: (Мужской/ женский)
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Height:
Рост:
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Address:
Адрес:
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Phone:
Телефон:
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Fax:
Факс:
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E-mail:
Электронный адрес:
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Work Experience or Ship:
Опыт Работы или Судно:
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Next of Kin:
Ближайшие Родственники:
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Relationship:
Степень родства:
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Address:
Адрес:
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Phone:
Телефон:
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Fax:
Факс:
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E-mail:
Электронный адрес:
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Applicant’s Signature:
Подпись Заявителя:
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Date:
Дата:
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EXAMINATION AND CERTIFICATION OF SEAFARERS: COMPENDIUM
ANNEX 2
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| The Republic of lIberia
ministry of finance
bureau of maritime affairs
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PHYSICAL EXAMINATION REPORT/CERTIFICATE
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| LAST NAME OF APPLICANT
| FIRST NAME
| MIDDLE
INITIAL
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 DATE OF BIRTH
MONTH DAY YEAR
| PLACE OF BIRTH
CITY COUNTRY
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| EXAMINATION FOR DUTY AS:
MASTER *
MATE *
ENGINEER *
RADIO OFF *
SEAMAN *
| MAILING ADDRESS OF APPLICANT
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| MEDICAL EXAMINATION (SEE REVERSE SIDE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
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| HEIGHT
| WEIGHT
| BLOOD PRESSURE
| PULSE
| RESPIRATION
| GENERAL APPEARANCE
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| VISION:
RIGHT EYE LEFT EYE
| HEARING:
RT EAR_______________________LEFT EAR___________________________
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| WITHOUT GLASSES
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| WITH GLASSES
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| COLOR TEST TYPE: BOOK * LANTERN *
| Check if color
test is normal
| " YELLOW________RED_____GREEN________BLUE______
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| HEAD AND NECK
______________________________________________
| HEART (CARDIOVASCULAR)
___________________________________________________________
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| LUNGS _______________________________________
______________________________________________
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| SPEECH (RADIO OFFICER):
Is speech unimpaired for normal voice communication?_____________________________________________________________________________________________
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| EXTREMITIES:
UPPER ___________________________________________ LOWER_______________________________________________________________
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| Is applicant suffering from any disease likely to be aggravated by or to render him unfit for service at sea or likely to endanger the health of other persons onboard?
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_________________________________________________ ________________________________
SIGNATURE OF APPLICANT DATE
This signature be attired in the presence of the examining Physician
THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:__________________________________________________________________________
(Name of Applicant)
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| (HE) (SHE) IS FOUND TO BE (FIT) (NOT FIT) FOR DUTY AS A
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| (MASTER, MATE, ENGINEER, RADIO OFFICER OR SEAMAN)
NAME AND DEGREE OF PHYSICIAN__________________________________________________________________________________________________________
(PLEASE PRINT)
ADDRESS _______________________________________________________________________________________________________________________________
NAME OF PHYSICIAN’S LICENSING AUTHORITY_______________________________________________________________________________________________
DATE OF ISSUE OF PHYSICIAN’S LICENSE____________________________________________________________________________________________________
SIGNATURE OF PHYSICIAN_________________________________________________________________________________________________________________
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| | | | | | | | | | | | | | |
This certificate is issued by authority of Liberian Maritime Regulation 10.325(2) and in compliance with the requirements
of the Medical Examination (Seafarers) Convention 1946 (ILO No/ 73)
ANNEX 2
| MEDICAL REQUIREMENTS
All applicants for a Liberian license, Liberian Seaman's Identification and Record Book or certification of special qualifications shall be required to have a physical examination reported on the Liberian Medical Form (RLM-105M) completed by a licensed physician. The completed medical form must accompany the application for license (RLM-105), application for seaman's identity document (RLM-273), or application for certification of special qualifications (RLM-279). This physical examination must be carried out not more than 12 months prior to the date of making application for a license or certification of special qualifications or a seaman's book. Such proof of examination must establish that the applicant is in satisfactory physical condition for the specific duty assignment undertaken and is generally in possession of all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the following minimum requirements shall apply:
(a) All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered voice in better ear at 15 feet and in poorer ear at 5 feet.
(b) Deck license applicants must have (either with or without glasses) at least 20/20 vision in one eye and at least 20/40 in the other. If the applicant wears glasses, he must have vision without glasses of at least 20/160 in both eyes. Deck license applicants must have normal color perception and be capable of distinguishing the colors red, green, blue and yellow.
(c) Engineer and radio license applicants must have (either with or without glasses) at least 20/30 vision in one eye and at least 20/50 in the other. If the applicant wears glasses, he must have vision without glasses of at least 20/200 in both eyes. Engineer and radio license applicants must be able to perceive the colors red, yellow and green.
(d) An applicant's blood pressure must fall within an average range, taking age into consideration.
(e) Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy, insanity, senility, acute alcoholism, tuberculosis, acute venereal disease or neurosyphilis and/or the use of narcotics.
(f) Radio license applicants must have speech which is unimpaired for normal voice communication.
(g) Applicants for able seaman, ordinary seaman and junior ordinary seaman must meet the physical requirements for a deck officer's license.
(h) Applicants for fireman/watertender, oiler, wiper, tankerman and survival craft crewman must meet the physical requirements for an engineer officer's license.
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| IMPORTANT NOTE:
The yellow copy of form RLM-105M must accompany the application. The applicant should retain the original (white) of form RLM-105M as evidence of physical qualification while serving on board Liberian flag vessels.
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