FORM 1 [See Rule 2(b)] [See Rules 5, 7, 10(a) and 14(b)] Medical Certificate in respect of an applicant for obtaining a Learner's License / Driving License or renewal of Driving License PART - II (TO BE FILLED IN BY THE APPLICANT) 1. Name __________________________________________ 2. Son/Wife/Daughter of __________________________________________ 3. Permanent Address __________________________________________ __________________________________________ 4. Temporary Address __________________________________________ __________________________________________ Official Address __________________________________________ __________________________________________ 5. Date of Birth __________________________________________ 6. Identification Mark 1) ________________________________________ 2) ________________________________________ Declaration as to physical fitness to be given by the applicant 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 ar a distance of 25 meters in good day light (with glasses if worn) Yes / No c) Have you lost either hand or foot are you suffering from any defect in movement, control 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 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 Space for Photograph of the Size Five Centimeters by Six Centimeters 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 he best of my knowledge and belief, the particulars given above and the declaration made herein are true Signature of Applicant Note: As applicant who answers "Yes" to any of question [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 given further information relating thereto. PART II [To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person authorized in this behalf by the state Government referred to under sub section (3) of section 8] 1. Name of the Applicant ________________________________ 2. Son / Wife / Daughter of ________________________________ 3. Permanent Address ________________________________ 4. Temporary Address ________________________________ 5. Date of Birth ________________________________ 6. Identification Mark 1) ________________________________ 2) ________________________________ 7. a) If the applicant to the best of your judgment subject to epilepsy, vertigo or any mental ailment likely to affect his driving efficiency ? Yes / No b) Does the applicant suffer from any heart or lung disorder which might interfere with the performance of his duties as a driver ? Yes / No c) Is there any defect of vision? If so, has it been corrected by a suitable spectacle Yes / No d) Can be applicant readily distinguish the pigmentary colours red and green ? Yes / No e) Does the applicant's suffer from a degree of deafness which would prevent his hearing the ordinary sound signals. Yes / No f) Does the applicant suffer from night blindness? Yes / No g) Has the applicant any 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 h) Does he show any evidence of being addicted to excessive use of alcohol, tobacco or drugs ? Yes / No i) Does he suffer from attacks of loss of consciousness from any cause ? Yes / No j) Is he able to distinguish with each eye at a distance of 25 meters in good day light a motor car number plate ? Yes / No k) Is he suffering from defect in movement control or muscular power of either arm or limb Yes / No l) What is the height of applicant? Consider that this height will be disadvantageous for him to have a clear vision of the road while driving. Yes / No m) Is he mentally ill person Yes / No n) Does he suffer from any other disease or disability likely to cause his driving a motor vehicle a source of danger to the public? Yes / No o) Is he in your opinion generally Fit as regards [i] bodily health [ii] eye sight [iii] mental ability [iv] hearing ability Yes / No p) Blood Group of the applicant ______________ q) RH Factor of the applicant ______________ I have examined the applicant I am of the opinion that he is not fit to hold a Driving licence for the following reasons: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Signature ________________ Name and Designation of the Medical Officer ____________________ ___________________________ Date _______________ I certify that I have personally examined the applicant ________________________ I also certify that while examining the applicant I have directed special attention to the distant vision and hearing ability, the condition of the arms, leg, hands and joints of both extremities of the Candidate and he is medically fit to hold a Driving License. Signature ________________ Name and Designation of the Medical Officer _____________ ___________________________ Date _______________ SEAL _______________________ Signature of Candidate Note: 1. The Medical Officer shall affix his signature over the photograph n such manner that part of his signature is upon the photograph and on the certificate 2. Particulars of the Gazette where the Medical Officer's appointment is notified with reference to Sub-Section (3) of section 8 of the Motor Vehicles Act, 1988 and Serial number in the list where his name appears. a) Blood Group of the applicant b) RH Factor of the applicant I have examined the applicant I am of the opinion that he is not fit to hold the Driving license foe the following reasons: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Signature ________________ Name and Designation of the Medical Officer _____________ ___________________________ Date _______________ I certify that I have personally examined the applicant ________________________ I also certify that while examining the applicant I have directed special attention to the distant vision and hearing ability, the condition of the arms, leg, hands and joints of both extremities of the Candidate and he is medically fit to hold a Driving License. Signature ________________ Name and Designation of the Medical Officer _____________ ___________________________ Date _______________ SEAL _______________________ Signature of Candidate Note: 1. The Medical Officer shall affix his signature over the photograph n such manner that part of his signature is upon the photograph and on the certificate 2. Particulars of the Gazette where the Medical Officer's appointment is notified with reference to Sub-Section (3) of section 8 of the Motor Vehicles Act, 1988 and Serial number in the list where his name appears.
