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This Medical Certificate has been issued in accordance wit the provisions of the (International Convention on Standards of Training, Certification and
Watch-keeping for Seafarers STCW 1978, as amended (STCW) Regulation I/9, Maritime Labour Convention 2006 (MLC 2006) Regulation 1.2 and
regulation of the authorizing country* as applicable.
SEAFARER INFORMATION
Family Name: Given Name(s): Exam Date: Birth Date (day/month/year): Gender:
Male Female
Passport No./Seaman Book No.: Home Address:
Are there any limitations or restrictions on fitness (e.g. specific position, type of ship, trade area)? If so, specify the limitation:
SIGNATURE
I hereby confirm that the medical examination has been carried out in accordance
with the ILO/IMO Guidelines on the Medical Examinations of Seafarers and the I __________________________________ (seafarer name)
national guidelines of my Authorizing Administration. confirm that I have been informed of the content of certificate
and the right to get a review***.
*For persons who are assigned shipboard safety, security or environmental protection duties, the medical standards referenced on the certificate are
the standards as specified in STCW Regulation I/9 and any other standards as specified by the authorizing Administration. For any other persons
serving onboard, the medical standards shall be as specified by ILO and the authorizing Administration of Malta and the Bahamas.
** The Medical Practitioner shall be approved by the national Administration, after inspection of medical facilities/recordkeeping, to carry out
STCW/ILO medical examination.
***The review shall be carried out by a body/Medical Practitioner authorized by national Administration and this information should be made
available to the seafarer.
RCL Medical Certificate for Service at Sea Revised 2015-03.docx ORIGINAL give to Employee to take to Ship Medical Page 1 of 1