APPLICATION –CUM-DECLERATION AS TO MEDICAL FITNESS

FORM 1

[See Rule 5(2)]

APPLICATION –CUM-DECLERATION AS TO MEDICAL FITNESS

1.       Name of applicant                             

2.        Son/Wife/Daughter of                    

3.        Permanent address                      

4.        Temporary address                         

       (if any)                                     

                                                                                                                                          

                                                                    

5.       (a) Date of birth                                                     

(b) Age on the date of application 

      6.    Identification marks                (1)            

                                                                           

                                                          (2)             

                                                                           

Declaration:

(a) Do you suffer from epilepsy or from sudden attack of loss of consciousness or giddiness from 

     any cause? Yes/No

(b) Are you able to distinguish with each eye(or if you have held a driving license to drive a   motor vehicle for a period not less than 5 years and if you have lost sight of one eye after the said period of 5 years and 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 metes 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 primary colors red and green?  Yes/No

(e)Do you suffer from night blindness?  Yes/No

(f) Are you so deaf 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 a motor vehicle source of danger to public, if so give details Yes/No
I hereby declare that, to the best of my knowledge and belief, the particulars furnished and the declaration therein are true.

                                                                                         Signature or thumb impression of the applicant

Note:(1) An applicant who answers yes to any questions (a), (c), (e),(f) and (g) or No to either of the questions (b) or (d) should amplify his answers with full particulars and may be required to give further information relating thereto.

 (2) The declaration is to be submitted invariable with medical certificate in from 1 A