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City <br />E <br />Pre-Authorization Form <br />Wage Incentive <br />Program <br />for the Physical Fitness Component <br />Use this form if, due to illness or injury, you are unable to participate in one or <br />more of the tests defined in the policy. <br />This form is to be submitted and approved PRIOR to the testing date. <br />Your name: (please prznt) <br />Date submitted: <br />I am unable to participate in <br />due to <br />Please <br />as an alternate. My requested alternate is comparable to the test I am unable to complete for the <br />following reasons: <br />Please attach any documentation that will confirm your illness or injuryT and any documents that <br />identif�T ho`v the requested test is a comparable alternative. <br />❑ Your request is approved. <br />❑ Your request is not approved for the follo`ving reason: <br />Human Resources Manager <br />Date <br />Kiver <br />