Appendix 3Appendix 3

Appendix 3

Form of Certificate of Medical Fitness

<table cellspacing="0" cellpadding="0" style="width:496.15pt; margin-top:0pt; border-collapse:collapse"><tbody><tr><td colspan="45" style="width:485.35pt; border-top:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><h2 id="navPoint_32" style="margin-top:6pt; margin-bottom:12pt"><span style="font-family:'CG Times (W1)', serif">Certificate of Medical Fitness</span></h2></td></tr><tr><td colspan="7" style="width:101.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Name</span></p></td><td colspan="19" style="width:159.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:1.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Header" style="margin-top:0pt; border-bottom-style:none; padding-bottom:0pt"><span style="font-family:'CG Times (W1)', serif">Sex</span></p></td><td colspan="4" style="width:31.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="10" style="width:119.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">PIN</span></p></td></tr><tr><td colspan="7" style="width:101.65pt; border-right:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif">Last name</span></p></td><td colspan="19" style="width:159.3pt; border-left:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif">First names</span></p></td><td colspan="2" style="width:1.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="4" style="width:31.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif">Male</span></p></td><td colspan="10" style="width:119.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr><td colspan="7" style="width:101.65pt; border-right:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="19" style="width:159.3pt; border-left:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:1.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="4" style="width:31.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="10" style="width:119.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; font-size:8pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr><td colspan="7" style="width:101.65pt; border-right:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="19" style="width:159.3pt; border-left:0.75pt dotted #000000; padding-right:5.4pt; padding-left:5.03pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:1.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="4" style="width:31.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif">Female</span></p></td><td colspan="10" style="width:119.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:8.45pt"><td colspan="10" style="width:132.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Header" style="margin-top:6pt; border-bottom-style:none; padding-bottom:0pt"><span style="font-family:'CG Times (W1)', serif">Home address</span></p></td><td colspan="3" style="width:14.95pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="19" style="width:166.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="10" style="width:125.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:24pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Proof of identity</span></p></td></tr><tr><td style="width:8.75pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="8" style="width:90.85pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif">Photo driver’s licence</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="7" style="width:51.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif">Passport</span></p></td><td colspan="3" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="8" style="width:62.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:6pt"><span style="font-family:'CG Times (W1)', serif">Other (specify)</span></p></td><td colspan="16" style="width:182.65pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'CG Times (W1)', serif">I have evaluated the above-named applicant according to Marine Orders, Part 9, made under the </span><span style="font-family:'CG Times (W1)', serif; font-style:italic">Navigation Act 1912</span><span style="font-family:'CG Times (W1)', serif">. On the basis of the applicant’s personal declaration, my clinical examination and diagnostic test results recorded on the medical examination form, I declare the applicant:</span></p></td></tr><tr style="height:4.75pt"><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Fit</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#e5e5e5"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Unfit*</span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Deck Department</span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif">* If found unfit, please provide details and action taken (eg referral or any practical tests required before fitness can be</span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif">certified)</span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Fit</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Unfit*</span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Engine Department</span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Fit</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Unfit*</span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Catering Department</span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:0pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:17.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Fit</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:3pt; margin-bottom:3pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:28.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Unfit*</span></p></td><td colspan="11" style="width:97.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">Other services</span></p></td><td colspan="26" style="width:264.5pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:0pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="2" style="width:11.45pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:22.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="5" style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="4" style="width:23.25pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="5" style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="5" style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="4" style="width:23.2pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:23.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:24.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:4.65pt"><td colspan="14" style="width:159.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">The applicant used aids to vision</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="4" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Yes</span></p></td><td colspan="3" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="2" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">No</span></p></td><td colspan="20" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="30" style="width:305.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="6" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:5.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="14" style="width:159.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Colour vision test done</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="4" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Yes</span></p></td><td colspan="3" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="2" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">No</span></p></td><td colspan="20" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="30" style="width:305.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="6" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:5.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="14" style="width:159.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Colour blind</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="4" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Yes</span></p></td><td colspan="3" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="2" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">No</span></p></td><td colspan="20" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="30" style="width:305.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="6" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="3" style="width:45.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:14.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td><td colspan="2" style="width:5.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:6pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="14" style="width:159.3pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">The applicant used aids to hearing</span></p></td><td colspan="2" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="4" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="FootnoteText" style="margin-top:6pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold">Yes</span></p></td><td colspan="3" style="width:11.9pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; font-size:10pt"><span style="font-family:'CG Times (W1)', serif; font-weight:bold"></span></p></td><td colspan="2" style="width:17.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="tableheader" style="margin-top:6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'CG Times (W1)', serif">No</span></p></td><td colspan="20" style="width:213.15pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:0pt; font-size:10pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:4.65pt"><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Header" style="margin-top:6pt; border-bottom-style:none; padding-bottom:0pt"><span style="font-family:'CG Times (W1)', serif">Describe any restrictions (eg specific position, type of ship, trade area)</span></p></td></tr><tr style="height:4.65pt"><td colspan="45" style="width:485.35pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#bfbfbf"><p class="FootnoteText" style="margin-top:6pt; margin-bottom:60pt"><span style="font-family:'CG Times (W1)', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:19.55pt"></td><td style="width:2.7pt"></td><td style="width:28.3pt"></td><td style="width:5.2pt"></td><td style="width:17.5pt"></td><td style="width:5.2pt"></td><td style="width:34pt"></td><td style="width:0.5pt"></td><td style="width:8.25pt"></td><td style="width:22.2pt"></td><td style="width:0.5pt"></td><td style="width:2.55pt"></td><td style="width:22.7pt"></td><td style="width:0.95pt"></td><td style="width:10.85pt"></td><td style="width:11.85pt"></td><td style="width:10.4pt"></td><td style="width:3.1pt"></td><td style="width:14.55pt"></td><td style="width:0.3pt"></td><td style="width:7.85pt"></td><td style="width:8.2pt"></td><td style="width:6.65pt"></td><td style="width:16.05pt"></td><td style="width:12.3pt"></td><td style="width:10.35pt"></td><td style="width:11.35pt"></td><td style="width:0.55pt"></td><td style="width:8.25pt"></td><td style="width:13.2pt"></td><td style="width:6.9pt"></td><td style="width:5.1pt"></td><td style="width:22.7pt"></td><td style="width:7.85pt"></td><td style="width:6.9pt"></td><td style="width:7.25pt"></td><td style="width:12pt"></td><td style="width:13.5pt"></td><td style="width:20.6pt"></td><td style="width:22.7pt"></td><td style="width:13.4pt"></td><td style="width:21.55pt"></td><td style="width:3.95pt"></td><td style="width:14.25pt"></td><td style="width:1.6pt"></td></tr></tbody></table>