Candidate Physical Ability Test - Mississippi Department of Insurance

Candidate Physical Ability Test (CPAT)
Application Package
Steps to apply for the Candidate Physical Ability Test:
____ MSCB Personnel Action Form complete
____ Current MSFA Application for Admission complete and signed
____ CPAT Sign In Sheet complete
____ CPAT Waiver of Claim for Injury complete
____ MSCB Request for Exclusion for CPAT Orientation complete
Information:
1. MSCB Personnel Action form should be sent to Lynn Tyler at the Fire Academy.
2. The MSFA Application for Admission, Sign In Sheet, Waiver, and Request for
Exclusion should be sent to Gladys Peterson at the Fire Academy.
3. Students shall wear long pants to test in on their scheduled test date.
4. Students should come with a valid driver’s license to ensure identity before
testing.
**This does not guarantee the student a position for the next scheduled test. The
department will receive a confirmation letter from the Academy indicating the testing
date assigned.

Candidate Physical Ability Test
Sign In Sheet
Last Name:______________________ First Name:____________________ MI:____
(please print)
Street Address:________________________________________________________
City:____________________ State:_______ Zip Code:_______________________
Telephone #:__________________________
Driver’s License #:____________________ MSFA ID #:_______________________
(First 3 letters of last name, first 2 letters of first name, last 4 of SS#)
Date of Birth:___________________________
In case of emergency, I authorize you to contact:
Name:________________________________________________________________
Telephone #:______________________________
Applicant Signature:_____________________________ Date:___________________

Candidate Physical Ability Test
Waiver of Claim for Injury
This form must be signed before you will be permitted to participate in the Candidate
Physical Ability Test.
You will be asked to perform eight (8) physical tasks and will be given specific
instructions (by videotape and proctors) in the manner in which these physical tasks are
to be performed. The eight (8) physical tasks are:
1. Stair Climb
2. Hose Drag
3. Equipment Carry
4. Ladder Raise and Extension
5. Forcible Entry
6. Search
7. Rescue
8. Ceiling Breach and Pull
I have read and understand the physical effort which the Candidate Physical Ability Test
involves. I am physically capable of participating in this test. I hereby waive any and all
claims for or arising out of any injury I might sustain or incur as a result of participating
in the Candidate Physical Ability Test. I voluntarily participate as part of my application
for employment.
Last Name (please print) First Name MI.
Applicant Signature
Date

Mississippi Fire Academy
Mississippi Fire Personnel Minimum Standards and Certification
Board
Request for Exclusion
I the undersigned do hereby, knowingly and admittedly formally request that I be
excluded from participating in the Candidate Physical Ability Test Candidate Orientation
Sessions. I understand the two orientations have been offered to me in an attempt to
better prepare me for the Candidate Physical Ability Test. These orientations will allow
me the opportunity to receive “hands on” familiarity with test apparatus and the test. I
do hereby refuse these orientations on my own merit, and being under no influence by
any other person or persons.
I do hereby acknowledge that I have read and understand the aforementioned
information regarding my participation in the Candidate Physical Ability Test Orientation.
Witnessed by my signature below.
Candidate Name:_______________________________________________________
(please print)
Candidate Signature:_______________________________ Date:_________________
Witness Signature:_________________________________ Date:_________________