FORM~I-A

Medical Certificate
(See Rules 5(1), (3), 7, I0(a)14 (b) and t8(d)

,. ('fd' be (llled In by a registered medical practitioner appointed for the State govemmtnf or
:' person authorised in this behalf by the State Government refer re~ to under 1ub-section (3) of section 8)
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1. Name or the AppHcanL......- ..... MU•MM . . . M . . . . . . . . . . . . . . . . . - - tL..~..:::.:.:;;._J<;. ....._..........- -
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· 3. Identification marks : (1) ................ - ............ :: ....................._ , ............... -

(2) ···········................. -••················································ . ········•.........,............

S. (a) Does the applicant to the best of your judgement suffer from any defect Yes/No /
of vision ? If so, has it been corrected by suitable spectacle ?
· (b) Can the applicant to the best of your judgement readily distinguish the
pigmentary colours, red and green ?
(C) In your opinion is he able to distinguish with his eye sight at a distance
Je~
of 25 meters in good day light a motor car number plate.
_;,,{.s1No, /
(cl) In your opinion does the applicant suffer from a degree of deafness
which would prevent his hearing the ordinary sound signals '! Ves/No /
Ve#i'No
(e) In your opinion does the applicant suffer from night blindness ?
(f) Has the applicant any defect or deformity or loss of number which
, would interiere with the efficient performance of his duties as a driver?
If so, give your reasons in details.
(g),..··•••·•·····•··•••••••.. "-········............................................................ --·····...............-
Optional
(a) Blood Group of the applicant (if the applicant so desire that the
information may be noted in his driving licence)
(b) RH factor of the ap.plicant (if the applicant so desire that the
information may be noted in his driving licence)
Dccl<a.ration made by the applicant in Form-I as to·his physical fitness is attached

I mt;fy that I ba,e prnonally examined the applicant ..................... ~ ---~

l also certify that while examining the applicant I have directed special attention to the
distant vision sad hearing ability, the; condition of the arms, legs, hands and Joints of
both extermitie~ of the candidate and to best of my judgement he is medic y fitlnot fit
to hold a driving licence. •
The applicant i, not medicaDy fit to bold a licence for the following reasons :,

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Signature: l.... ~t>-\ ,
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., \ ) , ~ 'NJJQt'"pd desi20ation of . c lffi;~i! ractitione, .
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1 ~~~t :·: J\~~ \r' Seal) ~ 7

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"'° -~ vp- .
i. ~o'ltl~~ ., ::oHiedical Officer

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,!•rt __ , Slpature or thumb lmpreslon.of the candidate
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note.: The Medical lfth lab ()fflcs dlall signature over the photograph affixed in such a .
• that pan of If apon biJ apature tbc pboto&rapb and part on the certificat.
 FORM-I _
_. · (See .Rule 5 (2)
Applicado~m-d clarati~n to be pfly!ltal fitness
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I. Name·of1Jie applicant.. ........... A..~{-~ ~ ---~ --:;:·-··-~-- . .......
'2. Son/Wife/daughter of. ........... - ...... :....~. .... __ :...... ... ..... ..'u ····---."',_. . .' . .
;L~::i..S.,
!I.a Permanent address... __ B._- <2 ·· .;v l L l -==--~Ja-0-L..:_ -<

(a) Temporary address .• __:__, "' • .. ----/-14-~ -----_;_

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(b) Age on date of applica'f1on - • • •_ _ _ ______ {
6. ldcntification Marks (I),_.. _ _ _____ ~ -·-·-·
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Declaration:
fA) Do you suffer from opilepsy, or from ·suddm- attacks ., loss of
) consciousness or giddiness from any case&

An you- able to distinguish nith (Ye (or If you held a drivinc

licence to drive a motor vehicle for a period of not less than five
· Jean and if you have lost,.the .sight of one eye after the said period
ef five years and if the application is for driving a light motor
yehicle other than II transport vehicle fitted with an outside mirror
en the steering wheel side} 1>r with one eyef at a distance of 25 rnetra
10 good day light (with glasses. if worn) a motirr car number plate ?
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_(C) Have you lost either hand or foot or are your suffering from any defect
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of
or muscular power either amt or leg? Ye&IN:/
(I)) Can you readily distinguish the pigmentar, coloun, ~d uid- f ctea1No
(E) Do you ruffer from riight blindness ! ·'
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(F) All! you lo deaf as to · be unable ro hear (and if the application Is for
t
. driving a ligiu mo1vr vehicle, wit.la • wWtout hearine aid. tht
ordinary souad lienaJ?

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(G) Do yo·u suffer from any other disease or dbability 1ikely n, cause your.
dri ving of a motor vehicle lo be a source of danger to the public, if
so , give details. · ·Yes/No :

I hereby declare that . to the best of my knowled ge and belief, the particulan given
above and the declaration made therein are true. !

or
mb Impression o.f the applicants)
!Sole; (I) An applicant, who answer' .yes to an o the question (a), (c), (el, (0 and (g)
-......,.. or 'No' 10· either of the question (b) and (d) should amplify his .answer with
full parricuars, and may be required to give further information thereto.
(2) This declaraJioD.. N _11&1,>IDi«ed i_nvisiabt, witb medkaJ certjficate ia
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' from :. 1A
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