AMSA forms

1. Do you have unclear speech or hesitation when you speak?

   Yes No
2. Do you have trouble hearing a whispered voice or a watch ticking? Hearing aids are acceptable provided that their use does not impede watch keeping duties to be adequately performed.

   Yes No
3. Do you have a hernia that has not been corrected satisfactorily by a curative operation?

   Yes No
4. Do you have any artificial limbs? Is any artificial limb likely to prevent you from performing duties on a commercial vessel?

   Yes No
5. Do you have a cardiac pacemaker implanted?

   Yes No
6. Have you ever suffered from epileptic seizures?

   Yes No
7. Do you have insulin dependent diabetes or any form of controlled diabetes

   Yes No
8. Have you been affected by pulmonary tuberculosis?

   Yes No
9. Are you suffering from any medical condition or are you aware of a physical or mental capacity that may affect your ability to perform duties under this certificate?

   Yes No

If you answered ‘Yes’ to any of the above, a medical examination and report by a qualified medical practitioner is required.

• to the best of my knowledge and belief I am physically fit and there is no other medical condition or disability likely to prevent me from performing duties effectively as a crew member aboard a commercial vessel.
• to the best of my knowledge the information provided by me in this application (and any attachments I have included with this application) is true and correct.
• I consent to the Australian Maritime Safety Authority, as the National Regulator, making all reasonable enquiries in order to verify that the information provided by me in this application (and any attachments I have included with this application) is true and correct.
• I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask that I provide any information or document that the National Regulator reasonably considers necessary for consideration of this application.
• I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask another person to provide any information, document or agreement that the National Regulator reasonably considers necessary for consideration of this application.