Firefighter Medical Certificate Form
Submit this form to request a firefighter medical certificate. Please complete all relevant sections accurately.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fire Department / Organization
*
Rank or Position
Date of Medical Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examining Physician's Name
*
Physician's Confirmation of Fitness for Duty
*
Fit for duty
Not fit for duty
Physician's Signature
*
Submit
Submit
Should be Empty: