Order on a Druggist

Issued in accordance to the World Health Organisation (WHO)

International Medical Guide

PART (A) – ORDER REQUEST
Name and Address of Druggist
Name of Vessel	Official No.

Please replenish the medicines and medical stores of the above vessel in consultation with a qualified medical professional, such as the ship’s doctor or medical consultant, or in accordance to Table I as set out in Annex I of Marine Circular MC-2/2007/12/2 as applicable to a vessel with the following conditions:

Vessel Type	:

Voyage duration	:

No. of persons on board	:

Date	Signature of Master / Owner*
PART (B) – CERTIFICATE
Declaration by Registered Pharmacist

I have inspected the ship’s medical chest and have replenished the medicines and medical supplies in accordance with the above instructions.

I hereby certify that the contents in the ship’s medical chest are in satisfactory condition and are in accordance with Marine Circular MC-2/2007/12/2 except for the items listed below.

List of Items Not Supplied

Date	Signature of Registered Pharmacist

Instructions:

Reference should always be made to Marine Circular MC-2/2007/12/2.

PART (B) is to be completed by a registered Pharmacist and thereafter submitted to the Tuvalu Ship Registry by the Master/Owner.

If the medicines and medical supplies cannot be replenished fully in accordance with Marine Circular MC-2/2007/12/2, then the items that are short supplied need to be listed in PART (B) and the Master should be notified.

TVR/DRUGGIST/2012/REV.1	Page 2 of 1

TVR/DRUGGIST/2012/REV.2	Page 1 of 1

*delete as appropriate

SPECIAL VOYAGE PERMIT

david

2012-07-13