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Vanuatu Consolidated Subsidiary Legislation |
Commencement: 21 July 2005
MEDICAL CERTIFICATE (PRESCRIBED FORM)
Order 24 of 2005
1. Prescribed Medical Certificate
The Prescribed Medical Certificate referred to in sections 46A(4) and 46B(6) is as set out in the Schedule.
SCHEDULE
Prescribed Medical Certificate
| Name of Applicant | | Address of Applicant | | |||
| Date of Birth | | Height | | Color of eye | | |
| Vision Right Eye | | Color Vision | | | | |
| Vision Left Eye | | Urine Albunem | | Sugar | | |
| Please place a tick on the boxes below ? | ||||||
| | Normal | Abnormal | ||||
| Heart | | | ||||
| Lung | | | ||||
| Ears | | | ||||
| Abdomen | | | ||||
| Central Nervous System | | | ||||
| Joints | | | ||||
| Comment | | Official Stamp |
I declare to the best of my Knowledge that the applicant does not suffer from any illness or physical handicap which could result in the said person being a public danger whilst in charge of a motor vehicle.
Name of Doctor: ...........................................................................
Signature ........................ Date:........./........../.........
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URL: http://www.paclii.org/vu/legis/consol_sub/mcf265