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Get Peme Form 2019-2024

/ (dd/mm/yyyy) PHOTOGRAPH Name: Last Name First Name Middle Name Mailing Address: Date of Birth (dd/mm/yyyy) Blood Type/Group Place of Birth (City/Country) Medical Certificate No.: Name of Ship/Vessel Seafarer s Certificate No.: Seafarer s Signature NOTE: The passing or failure of the medical examinations for the following is based upon the 2019 American Club Pre-Employment Medical Examination Guidelines. All relevant examinations must be completed and recorded below.

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