Medical Form - Substitute Operator Request

Part A - To be completed by the licence holder

Information about the person with the impairment (please print)

Substitute operator and licence information (please print)

Part B - To be completed by the qualified medical doctor (please print)

Duration of impairment (Please be specific)

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.