MEDICAL FITNESS FORM FORM A01

 FORM A01 MEDICAL FITNESS FORM This form should be printed out, duly filled and presented by Candidates before they take 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 PERSONAL INFORMATION 1.
Surname 2. Name/Other Names 3. Date of Birth: Gender: Marital Status-­‐-­‐ 5. Zone of FAAN Recruitment Exercise: 6. Residential Address: 4. State of Origin/L.G.A: 7. Phone No: Email Address 8. Name of Next of Kin: 9. Address of Next of Kin: 10. Phone Number of Next of Kin: 11. CANDIDATE CERTIFICATION I, (insert your name) who applied for a job with the Fire Department or Security Department of FAAN certify that, I am physically fit to take the Physical Fitness Test exercise. I certify that I have no known existing condition or sickness that may prevent me from taking part in the exercises. I hold FAAN, the officials, and other organizations involved in the programme free of any blame for any loss from injuries or accidents arising from activities related to the fitness test. I understand that I will not be entitled to claim any compensation or other relief should there be any injuries or death arising during the course of exercise. 12. APPLICANT’S SIGNATURE DATE: FORM A02 DOCTOR’S REPORT (To be filled by an approved medical doctor only) 1.
Please Indicate medical condition/history with respect to the following: i.
Heart Disease: ii.
Diabetics: iii.
Hypertension: iv.
Asthma: v.
Ulcer: vi.
Pregnancy: vii.
Injuries/Surgeries: Other: 2. Height: 3. Weight: 4. BMI: viii.
DOCTOR’S DECLARATION I, Dr. of (Name of Hospital) hereby confirm that (Name of FAAN Candidate) has been cleared and certified fit to take part in the Physical Fitness Test. DOCTOR’S SIGNATURE & STAMP DATE