_________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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
_ Nonbinary
(Date of Birth)
INSTRUCTIONS TO HEALTHCARE PROVIDER:
Complete Part A unless certificate is limited --in which case complete Part B
A. I hereby certify that I have examined the above-named applicant and find they are
physically qualified for lawful employment.
(Date of Physical) (Signature of Healthcare Provider)
(Address of Healthcare Provider)
B. I hereby certify that I have examined the above-named applicant and find they have a
disability that requires limited employment.
(1) Disability ---
(2) Occupation ---
(3) Employer ---
(Date) (Signature of Healthcare Provider)
(Address of Healthcare Provider)
If a limited certificate is indicated, the disability, occupation, and employer must be indicated to make this
certificate valid.
