FORM

FORM 1

[ See rule 5(2)]

APPLICATION –CUM-DECLARATION AS TO PHYSICAL FITNESS

1. Name of the application _______________________________

2. Son/wife/daughter of _______________________________

3. Permanent address _______________________________

4. Temporary Address _______________________________

Official Address (if any) _______________________________

5. (a) Date of Birth _______________________________

(b) Age on date of application _______________________________

6. Identification marks (1) ____________________________

(2) ____________________________

Declaration,

(a)	Do you suffer from epilepsy or form sudden attacks or loss of consciousness or giddiness from any cause ?	______________________________
(b)	Are you able to distinguish with each eye (or if you have held a driving licence to drive a motor vehicle for a period of not less than five years and if you have lost the sight of one eye after the said period of five years ad if the application is for driving a light motor vehicle other than a transport vehicle fitted with an outside mirror on the steering wheel side) or with one eye, at a distance of 25 metres in good day light with glasses, if worn a motor car number plate ?	Yes/No
(c)	Have you lost either hand or foot or are you suffering from any defect of muscular power of either arm or leg. ?	Yes/No
(d)	Can you readily distinguish the pigmentary colours, red and green ?	Yes/No
(e)	Do you suffer from night blindness ?	Yes/No
(f)	Are you so deaf so as to be unable to hear (and if the application is for driving a light motor vehicle , with or without hearing aid) the ordinary sound signal ?	Yes/No
(g)	Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of danger to the public, if so, give details.	Yes/No

I hereby declare that , to the best of my knowledge and belief, the particulars given above and the declaration made therein are true.

(Signature or thumb impression of the applicant)

NOTES.- (1) An applicant who answers “Yes” to any of the questions (a), (c), (e), (f) and (g) or “No” to either of the questions (b) and (s) should amplify his answers with full particulars, and may be required to give further information relating thereto.

(2) This declaration is to be submitted invariably with medical certificate in Form 1A.

FORM 1A

[ See rules 5(1),(3),7,10(a),14(d) and 18(d)]

Space for 2[Passport size photograph]

MEDICAL CERTIFICATE]

(To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person authorised in this behalf by the State Government referred to under sub- section (3) of section 8)

1. Name of the application _______________________________

6. Identification marks (1) ____________________________

(2) ____________________________

3.	(a) Does the applicant, to the best of your judgment, suffer from any defect of vision? If so, has it been corrected by suitable spectacles.	Yes/No
	(b) Can the applicant, to the best of your judgement, readily distinguish the pigmentary coulour , red and green ?	Yes/No
	(c) In your opinion, is he able to distinguish with his eyesight at a distance of 25 metres in good day light a motor car number plate ?	Yes/No
	(d) In your opinion, does the applicant suffer from a degree of deafness which would prevent his hearing the ordinary sound signals ?	Yes/No
	(e) In your opinion, does the applicant suffer from night blindness ?	Yes/No
	(f) Has the applicant any defect or deformity or loss of member which would interfere with the efficient performance of his duties as a driver ? If so, give your reasons in details.	Yes/No Optional ..............................................................
	(g)(a) Blood group of the applicant (if the applicant so desires that the information may be noted in his driving licence)
	(b) RH factor of the applicant (if the applicant so desires that the information may be noted in his driving licence)

Declaration made by the applicant in Form 1 as to his physical fitness is attached.

[Certificate of Medical Fitness ]

I certify that :

(i) I have personally examined the applicant Shri/ Kum....................................

(ii) that while examining the applicant I have directed special attention to his/her distant vision;

(iii) while examining the applicant, I have directed special attention to his/ her hearing ability, the condition of the arms, legs, hands and joints of both extremities of the applicant; and

(iv) I have personally examined the applicant for reaction time, side vision and glare recovery, (applicable in case of persons applying for a licence to drive goods carriage carrying goods of dangerous or hazardous nature to human life.

And , therefore, I certify that, to the best of my judgement , he is medically fit/not to hold a driving licence]

The applicant is not medically fit to hold a licence for the following reasons.

1. Name and designation of the Medical Officer/ practitioner.

(seal)

2. Registration number of medical officer.

Date......................... Signature or thumb impression of the candidate.”

NOTE.- The medical officer shall affix his signature over the photograph affixed in such a manner that part of his signature is upon the photograph and part on the certificate.