FORM
1
APPLICATION-CUM-DECLARATION
AS TO PHYSICAL FITNESS
1.
Name
of the Applicant:
__________________
__________________
2.
Son/Wife/Daughter
of: __________________
__________________
3.
Permanent
Address: __________________ __________________
4.
Official
/ Temporary __________________
address (if any)
__________________
5. Date of Birth Date
____ Month ____Year_____________
Age on date of
application __________________
6. Identification
marks
(1) __________________
(2) __________________
DECLARATION:
(a) Do you suffer from epilepsy
or from sudden attacks 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 of not less than five years and if you have lost, the sight of one
eye after the said period of five years and if the application is for driving a
motor vehicle other than a transport vehicle fitted with an outside mirror on
the steering wheel side) or with 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 a defect or 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 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 gives above and the declaration
made therein are true.
(Signature or thumb impression of
the application)
Note : (1) Applicant
who answers `Yes' to any of the questions (a), (c), (e), (f) and (g) or `No' to
either of the questions (b) and (d) 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 certificate in Form 1-A.
Incoming Search Terms:
- Driving License Medical Declaration Form
- Driving License
- Driving Licence
- Medical Test
- International Driving License
- Medical Declaration
- Form 1
