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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