FORM 1A

[Refer Rules 5(1), (3), 7, 10a), 14) and 18(d))

MEDICAL CERTIFICATE
(To be filled in by aregistered medical practitioner appointed for the purpose by
the State Government or person authorised in this behaif by the State Govemment
referred to under sub-section (3) of section 8)
1. Name of the applicant RA..AvAIAS,. ADAV
lA Son/wife/ daughterof
Haut o t12, Glob Fasrm
BiecK-2Delhi
1B Permanent Address
Sangom Vihan Nes -1la o
Date of Birth]
2. Identification marks (1)....
Oa3) 10| 14s3
(2).
3 (a) Does the applicant, to the bst of your udgment, Yes/ N
siffer fron any defet of vision? If so, has it been
corected by suitable spectacles?
() In yor opinion, is he able to distinguish with his fes/ No
eyesight at a distance of 25 metres in good day light a
motor car numder plate?
() In your opinon, dos suffer trom a Yes/Ng
degree of deafness which teent his heartng
wuuld
the ardinary sound signals?
(e) In yor opinion, does the applicart sutfer frun Yes/ No
night blindness?
(0 Has the applicant any defecd or deformuty or loss Yes/ Ng
of member which would interfere with the eicient
perfonance of his duties as a drive? Ifso, give your
reasans in details
(g) Optina
(a) Blood group of the applicant (if the appicant so
desires that the infomation may be noted in hús
drìving licence)
b) RH actor of the applicant (if the applicant
in
so
his
desires that the infomation may be noted
driving licence)
 Decluutian mae by the qpplicant in Form I as to his pBysinl fitness is attoched]
Certificate of Medical Fitness
I certify that - /Kum. kAMAVAMAR JA0AV
have personally examined the applicant ShriISmt to
() that while exarnining the applicant I have directed special attention
his/her distant vision;
(iü) while examining the applicant, I have directed special attention to huS/ her
hearing ability the condition of the ams, Jegs. hands and joints of botih
extremities ofthe applicant; and
(iv) Ihave personally examined the appicant for reaction time, side vision and
lare recovery, (applicable n case of for a licence to drive
personsapns
goods cariage carrying goods of dangerous or nature to human
life).
(v) Applicant's colour vision has been tested using standard ishihara chart and
colour
the applicant has not been found suffering from severe or total
blindness.
And, therefore, I certifyto that, to the best of my judgement, he is medically ft/not
adapted vehicle.
ft to hold a driving licence drive a vehicle other than an follogingSfasohsX CHAUHAN
for the
The applicant is not medically fit to hold a licence Signature: 13.D.S.
1. Name and designation of the hedifat3
officer/ pracitioner
(Seal)

2. Registration number of medical

Signature ar thumb impression of the can
Date
shall afix his sigmature over the photograph afixed in
Notes 1:The medical officer
such a marner that part of his signature is upon the photograph and part on the
certificate.
without deafness may be granted a valid certificate of driving
2. Dumb persons
licence for non-transport vehicle.