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AGOLL VENTURES LIMITED

MEDICAL FITNESS CERTIFICATE

1. LAST NAME OF PERSONNEL 2. FIRST NAME 3. MIDDLE INITIAL

4. DATE OF BIRTH

MONTH / DAY / YEAR

5. PLACE OF BIRTH

CITY COUNTRY

6. SEX

MALE FEMALE

7. EXAMINATION OF DUTY AS:

CRANE OPERATOR OFFSHORE RIGGERELECTRICIAN OFFSHORE RIGGER FOREMAN

MACHINIST WELDER

MECHANIC OFFSHORE

NDT OPERATOR

PIPE FITTER

. MAILING ADDRESS OF PERSONNEL

E!"#$%

MEDICAL EXAMINATION &TURN O'ER FOR MEDICAL RE(UIREMENTS) STATE DETAILS ON REVERSE SIDE). HEIGHT 1*. WEIGHT 11. BLOOD PRESSURE 12. PULSE 13. BREATHING 14. GENERAL

APPEARANCE

15. VISION%RIGHT EYE LEFT EYE

16.HEARING

RIGHT EAR ++++++++++++++++++ LEFT EAR+++++++++++++++++

WITHOUT GLASSES

. WITH GLASSES

17. COLOR TEST TYPE% BOO, LANTERN COLOR TEST% YELLOW++++++ RED++++++ GREEN+++++ BLUE++++++

1 HEAD AND NECK

+++++++++++++++++++++++++++++++++++++++++++

1). HEART (CARDIOVASCULAR)

___________________________________________

2*.LUNGS____________________________________________

21. SPEECH (RADIO OFFICER):

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++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

22. EXTREMITIES% UPPER++++++++++++++++++++++++++++++++++++++ LOWER ++++++++++++++++++++++++++++++++++

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7/26/2019 8.1- AVL Blank Medical Fitness Report

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MEDICAL REUIREMENTS

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