THE INTERNATIONAL MERCHANT MARINE REGISTRY OF BELIZE

“IMMARBE”

MEDICAL FITNESS CERTIFICATE

IMMARBE
1. LAST NAME OF APPLICANT 2. FIRST NAME 3. MIDDLE INITIAL

4. DATE OF BIRTH 5. PLACE OF BIRTH 6. SEX

MONTH / DAY / YEAR CITY COUNTRY MALE 1 FEMALE 1

7. EXAMINATION OF DUTY AS: 8. MAILING ADDRESS OF APPLICANT
ASSISTANT ENGINEER OFFICER RATING
MASTER RATING AS PART OF THE ENGINEERING WATCH
CHIEF MATE RATING AS PART OF THE NAVIGATIONAL WATCH
CHIEF ENGINEER OFFICER TANKERMAN CERTFICATE
Email:
ENGINEER OFFICER DECK OFFICER
RADIO OPERATOR SECOND ENGINEER OFFICER

MEDICAL EXAMINATION (TURN OVER FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
9. HEIGHT 10. WEIGHT 11. BLOOD PRESSURE 12. PULSE 13. BREATHING 14. GENERAL APPEARANCE

15. VISION: 16. HEARING

RIGHT EYE LEFT EYE

WITHOUT GLASSES

RIGHT EAR _____________________ LEFT EAR__________________

. WITH GLASSES

17. COLOR TEST TYPE: BOOK 1 LANTERN 1 COLOR TEST: YELLOW______ RED______ GREEN_____ BLUE______
18 HEAD AND NECK 19. HEART (CARDIOVASCULAR)
________________________________________________ _______________________________________________

20.LUNGS____________________________________________________

21. SPEECH (RADIO OFFICER):

Is speech unimpaired for normal voice
communication?_________________________________________________________________________________________________________________________

22. EXTREMITIES: UPPER______________________________________ LOWER ______________________________________________

23. 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 on board?

_______________________________________________ _____________________
SIGNATURE OF APPLICANT MONTH/DAY/YEAR
This signature should be affixed in the presence of the examining Physician

24. THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:

____________________
DATE OF ISSUANCE

_____________________________________________________________ ________________________
(Name of Applicant) EXPIRATION DATE

THIS CERTIFICATE IS VALID FOR NOT MORE THAN TWO (2) YEARS.

(HE) (SHE) IS FOUND TO BE (FIT) FOR DUTY AS A: (SAME AS SECTION 7)

NAME AND DEGREE OF PHYSICAN____________________________________________________________________________

(PLEASE PRINT)

ADDRESS ___________________________________________________________________________________________________
NAME OF THE PRACTITIONER LICENSING AUTHORITY_________________________________________________________
DATE OF ISSUE OF PRACTITIONER’S LICENSE _________________________________________________________________

SIGNATURE OF PRACTITIONER__________________________________________________________

F-006-MFC /Rev 1 Page 1 of 2

 MEDICAL REQUIREMENTS

All applicants for A Belize Endorsement Attesting Recognition of a foreign Certificate shall be required to have
a physical examination reported on the Medical Fitness Certificate conducted by licensed physician. The
Medical Fitness Certificate must accompany application for Endorsement Attesting Recognition of a foreign
Certificate. This physical examination must be carried out not more than 24 months prior to the date of making
application for Endorsement Attesting Recognition a Certificate. 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 facilities 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 account.
(e) Applicants afflicted with any of the following disease 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.

IMPORTANT NOTE

The original or a certify copy must be carried on board by the seafarer while serving on board of a Belize Flag
vessel in order to prove that he/she is medically fit.

DETAILS OF MEDICAL EXAMINATION

(To be completed by examining physician)

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

F-006-MFC /Rev 1 Page 2 of 2