Medical Form - Substitute Operator Request Part A - To be completed by the licence holder Information about the person with the impairment (please print) First name and initial: Last name: Fisher Identification Number (FIN): Street No. and street name: City: Province: Postal Code: Date of Birth (yyyy-mm-dd): Signature of licence holder: Substitute operator and licence information (please print) First name and initial: Last name: Fisher Identification Number (FIN): Species: Licence Number(s): Part B - To be completed by the qualified medical doctor (please print) Specific effects of impairment: Duration of impairment (Please be specific) Duration of impairment From (yyyy-mm-dd): Duration of impairment To (yyyy-mm-dd): I certify that to the best of my knowledge the information given in Part B of this form is correct and complete and I understand that this information will be used by Fisheries and Oceans Canada to determine if my patient is eligible for substitute operator status on his/her commercial fishing licences. Doctor's signature: Date (yyyy-mm-dd): Doctor's printed name: Telephone du médecin :
