Fillable Printable Medical Fitness Form A01
Fillable Printable Medical Fitness Form A01
Medical Fitness Form A01
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MEDICAL!FITNESS!FORM!
This%form%should%be%printed%out,%duly%filled%and%presented%by%Candidates%before%they%ta ke%part%in%the%
Physical%Fitness%Test%(PFT)%Exercise."
FORM%A01%should%be%filled%by%the%candidate%%
FORM%A02%should%be%filled%by%a%qualified%Medical%Doctor%
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PERSONAL!INFORMATION!
1.Surname %%%%%%%%%%%%%
2.N am e/Other%Name s%%%%%%%%%%%
3.Date%of%Birth:%%%Gender:%%%Marital%StatusEE%%%%%
4.State%of%Origin/L.G.A:%%%%%%%%%%%
5.Zone%of%FAAN%Recruitment%Exercise:%%%%%%%%%
6.Residential%Address:%%%%%%%%%%
%%%%%%%%%%%%%
%%%%%%%%%%%%%%
7.Phone%No:%%%%%%Email%Addres s%%%%%%%
8.Name%of%Next%of%Kin:%%%%%%%%%%!
9.Address%of%Next%of%Kin:%%%%%%%%%%!
10.Phone%Number%of%Next%of%Kin:%%%%%%%%%!
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11.CANDIDATE!CERTIFICATION!
I,%%%%%%%%%%%%%%
%%%(insert%your%na m e)%who%applied%for%a%job%with%the%Fire%Department%or%
Security%Departme nt%o f%FA AN%certify%that,%I%am %ph ysica lly%fit%to%take%the%Physical%Fitness%Test%
exercise.%%I%certify%that%I%have%no%known%existing%condition%or%sickness%that%m ay%pre ve nt%me %from %
taking%part%in%the%exercises.%%I%hold%FAAN ,%the%officials,%and%other%organizations%involved%in%the%
programme%free%of% any%blame%for%an y%loss%from%inju r ie s %or%a cc iden t s %a r is in g %f rom %a c t iv it ie s %r e la t e d %to%
the%fitness%test.%%%I%u nd ersta nd%that%I%will%n ot%be%entitled%to%claim%any%com p en sation%or%oth er%relief%
should%there%be%any%injuries%or%death%arising%during%the%course%of%exercise.%
%
12.APPLICANT’S%SIGNATURE%%%%%%DATE:%%%%
FORM!A01!
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FORM!A02!
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DOCTOR’S!REPORT!(To!be!filled!by!an!approved!medical!doctor!only)%
1.Please%Indicate%medical%cond ition/history%with%respect%to%the%following:%
i.Heart%Disease:%%%%%%%%%%%
ii.Diabetics:%%%%%%%%%%%%
iii.Hypertension:%%%%%%%%%%%%
iv.Asthma:%%%%%%%%%%%%
v.Ulcer:%%%%%%%%%%%%%
vi.Pregnancy:%%%%%%%%%%%%
vii.Injuries/S ur ge ries : %%%%%%%%%%%
viii.Other:%%%%%%%%%%%!!
2.Height:%%%%%!
3.Weight:%%%%!
4.BMI:%%%%!
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DOCTOR’S!DECLARATION!
I,%Dr.%%%%%%%%%of%%%%%%
%%%%%%%(Name"of"Hospital)%hereby%confirm%that%%
%%%%%%%%(Nam e "of"FA A N"C and idate )%has%been%cleared%
and%certified%fit%to%take%par t%in%the%Phys ical%Fitness%Tes t.%
%%
DOCTOR’S%SIGNATURE%&%STAMP%%%%%%%%
DATE%%%%%%
