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Physical Fitness Certification

AT-16

THE UNIVERSITY OF THE STATE OF NEW YORK

THE STATE EDUCATION DEPARTMENT

Albany, New York 12234

PHYSICAL FITNESS CERTIFICATION

_________________________________________________________________________________________________

(Name of Applicant)

(Address)

______________________________

Male

Female

(Date of Birth)

INSTRUCTIONS TO PHYSICIAN:

Complete Part A unless certificate is limited --in which case complete Part B

I hereby certify that I have examined the above-named applicant and find he/she is

physically qualified for lawful employment.

________________________________________________________________________________________________

(Date of Physical)

(Signature of Physician)

________________________________________________________________________________________________

(Address of Physician)

I hereby certify that I have examined the above-named applicant and find he/she has a

disability that requires limited employment.

(1) Disability ---

(2) Occupation ---

(3) Employer ---

___________________________________________________________________________________________

(Date)

(Signature of Physician)

___________________________________________________________________________________________

(Address of Physician)

If a limited certificate is indicated, the disability, occupation, and employer must be indicated to make this

certificate valid.

Physical Fitness Certification