Physical Declaration

    Medical Inspection

    Date Issued

    Date of Expiry

    Country of Issue

    Malaysia

    Other

    Vaccination

    Date Vaccination

    Date of Expiry

    Country of Issue

    Yellow Fever

    Cholera

    Other

    Covid-19 Vaccination

    Vaccination Type

    Date Vaccination

    Country of Issue

    1st Dose

    2nd Dose

    HAVE YOU EVER SIGNED OFF DUE TO MEDICAL REASON? HAVE YOU EVER SUFFERED OR ARE SUFFERING FROM ANY AILMENT OR DISEASE THAT IS LIKELY TO RENDER YOU UNFIT FOR SEA SERVICE OR LIKELY TO ENDANGER THE HEALTH/WELL BEING OF OTHERS? DO YOU HAVE ANY BODILY DEFECTS OR DEFICIENSIES? ARE YOU ADDICTED TO ALCOHOL OR DRUGS OF ANY KIND? ARE YOU A MEMBER OF ANY RELIGIOUS OR POLITICAL GROUP? HAVE YOU EVER DEPORTED, DENIED VISA OR BANNED FROM ENTERING ANY COUNTRY? HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OR DRUG OFFENCE OR HAVE ANY PENDING OFFENCES? DO YOU HAVE ANY OBLIGATIONS TOWARDS YOUR CURRENT/ PREVIOUS EMPLOYERS?

    Medical History

    [multistep multistep-735 "https://southpointgroup.com/form-page-3/"]