DATE:

/

/

HEALTH CERTIFICATE

To Whom It May Concern:

Name:
Date of Birth:
Sex:
Address:

/

/

Age:
JAPAN

This is to certify that the above person has NO abnormalities on following physical
examination and laboratory examinations including:

Chest X-ray:
EKG:
Blood Chemistry:
Urinalysis:

Physician’s Signature: