Medical Certificate - Bupa
Medical Certificate 1 Before completing this certificate, see the back page for important information about pre-existing medical conditions 2 Please complete all details that are relevant to you, read the declaration and sign all the relevant signature panels 3
FORM 1-A MEDICAL CERTIFICATE - V A H A N
FORM 1-A [See Rules 5(1), (3), (7), 10(a), 14(d) and 18(d)] MEDICAL CERTIFICATE Space for passport size photograph [To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person
APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K
a medical certificate that satisfies the Maritime Labor Convention (MLC), AND want to be qualified for lookout duties should submit this form Sections III (Medical Conditions), IV (Medications) and V (Physical Examination) of the CG 719K DO NOT have to be completed The medical certificate will be restricted to entry-level only 3
Medical Certificate of Good Health
Medical Certificate of Good Health This certificate verifies that Mr /Ms is free of drug addiction, mental illness, and does not suffer from any disease that could cause serious repercussions to public health according to the specifications of the
Medical Examiners Certificate
Dec 06, 2015 · A complete Medical Examination Report Form, MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office Medical Examiner's Certificate Expiration Date Medical Examiner's Signature Medical Examiner's Telephone Number Date Certificate Signed Medical Examiner's Name (please print or type) MD DO
Medical Certificate Return to: Agency Name: Attn: Human
No sick leave, federal FMLA, state family/medical leave (C G S 5-248a), special leave with pay in excess of five (5) days, or leave as otherwise prescribed by contract, shall be granted state employees unless supported by a medical certificate filed with, and acceptable to, the appointing authority The period of incapacity
MEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIP
MPC 400 (11/1/10) CRMDSEGpageof MEDICAL CERTIFICATE GUARDIANSHIP OR CONSERVATORSHIP Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No This document will be used by the Probate and Family Court in the process of determining whether to appoint a guardian and/or conservator
MEDICAL CERTIFICATE FOR EMPLOYMENT INSURANCE SICKNESS BENEFITS
Name of Medical Doctor (Print)SpecialityArea Code Telephone NumberAddressSignature of Medical Doctor Date SC INS5140 (2017-01-005) E GIVE THE COMPLETED FORM TO THE PATIENT DISPONIBLE EN FRANÇAIS - INS 5140 F Date on which the above patient became unable to work due to their medical condition
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[PDF] Formalité 1 : certificat négatif - Fondation Création d 'Entreprises
Form MCSA-5876 (Revised: 12/06/2015)OMB No. 2126-0006Expiration Date: 8/31/2018
Medical Examiner's Certificate
(for Commercial Driver Medical Certification) U.S. Department of Transportation Federal Motor Carrier Safety AdministrationPublic Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless
that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 1 minute per response,
including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
I certify that I have examined Last Name:First Name:in accordance with (please check only one): the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49
) and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when
(check all that apply) OR the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49
) with any applicable State variances (which will only be valid for intrastate operations), and, with knowledge of the driving duties,
I find this person is qualified, and, if applicable, only when (check all that apply)Wearing corrective lenses
Wearing hearing aid
Accompanied by a waiver/exemption
Accompanied by a Skill Performance Evaluation (SPE) CertificateDriving within an exempt intracity zone (
49 CFR 391.62
(Federal)Qualified by operation of
49 CFR 391.64
(Federal)Grandfathered from State requirements
(State)The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,
MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.
Medical Examiner's Certificate Expiration Date
Medical Examiner's SignatureMedical Examiner's Telephone NumberDate Certificate SignedMedical Examiner's Name
(please print or type) MD DOPhysician Assistant
Chiropractor
Advanced Practice Nurse
Other Practitioner
(specify)Medical Examiner's State License, Certificate, or Registration NumberIssuing StateNational Registry Number
Driver's SignatureDriver's License NumberIssuing State/Province