Radiological Report

Immigration & Citizenship

Division

Department of Foreign Affairs

P.O. Box 422

WAIGANI, NCD

Papua New Guinea

Action Office:…………………………

Telephone:………………………….…

Our Reference:……………………….

Applicants aged 16 or more years are required to submit a 70mm, 100mm or full size plate chest X-ray

The film should be identified by the date taken and the full name of the applicant. This should be automatically inscribed during the photographic process if possible. If not, it should be written in English in white ink.

The migrant or student must sign below.

Attached Radiographer's report/results.

APPLICANT'S FULL NAME

(Block Letters)

APPLICANT'S SIGNATURE

(To be signed in radiographer's presence)

I hereby declare that I have carried out today an X-ray examination of the chest of the applicant whose signature is on this form.

Radiographer's Signature………………………………………………

Radiographer's Address………………………………………………….

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

Date / /19

_____________________________

Gov't. Print. – A3919/20 000. – 11.81