medicalcertificate(Annex).docVIP

medical certificate Annex Application of the law of the 15/12/1980 on the access to the territory, the stay, the establishment and the alienation of the foreigners Art 10 – 10bis 01/06/08 The undersigned Doctor in medicine full name ……………………………….…………………………………….. Certifies that he/she has examined this day Mr./Mrs./Miss full name ………………………………… …………………………………………………………………………………………………………………………………………….……….. Nationality ………………………………………………………………………………………………………………………….……….. Date and place of birth ……………………………………………………………………………………………………….……... Residing at …………………………………………………………………………………………………………………………….….… And has found him/her free of: Diseases being able to endanger the public health: Illnesses requiring quarantine aiming in the international regulation n°2 of May 25, 1951, of the World Health Organization; Pulmonary tuberculoses, active or progressive Other infectious diseases or contagious parasitoses in so far as they make, in the host country, the object of provisions of protection with regard to the nationals Issued at ……………………………………………………………. at ……..……….………………………………………………… Signature of doctor ……………………………………………………………….………….………………………………………… Stamp of doctor’s office …………………………………………………………….………………………………………………. Le cas échéant / In voorkomend geval, Visa de l’Ambassade ou du Consulat Général Visum van de Ambassade of het Consulaat-Generaal Sceau/stempel à/te ………………………………………………………….le/op …………………………………………………………………… Annex: Diseases being able to endanger the public health: Illnesses requiring quarantine aiming in the international regulation n°2 of May 25, 1951, of the World Health Organization; cholera; bubonic plague, smallpox, yellow fever Pulmonary tuberculoses, active or progressive Other infectious diseases or contagious parasitoses in so far as they make, in the host country, the object of provisions of protection with regard to the nationals typhus exanthema; febris recurrens; polio; epidemic influenza; typhoid and paratyphoid fever; salmonelloses; sig