medical certificate - Jakarta Marathon 2017

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Page 1. MANDIRI JAKARTA MARATHON 2016. RACE CATEGORY : MEDICAL CERTIFICATE. I, the undersigned, Doctor. ,. States that M
MANDIRI JAKARTA MARATHON 2016

RACE CATEGORY :

MEDICAL CERTIFICATE

I, the undersigned, Doctor

,

States that Mr/Mrs/Miss Date of Birth:

Age:

Is in healthy condition and is fit to participate in the running race. This medical certificate is issued in :

Date:

Doctor’s Signature & Stamp