FORM 1 [See Rule 5(2)] Application-cum-declaration as to the physical fitness 1. Name of the applicant 2. Son/Wife/Daughter of 3. Permanent address 4. Temporary address Official address (if any) 5. Date of Birth 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 licence to drive a motor vehicle for a period of no number plate? Yes/No (c) Have you lost either hand or foot or are you suffering from any defect or muscular power or 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 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 dange 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 (Signature or thumb impression of the applicant) Note: (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 ( 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 1-A 1. Subs. by Noti. No. GSR 933(E) dated 28-10-1989. Rule 5(2): An application for a medical certificate shall contain a declaration in Form 1.
