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Medical Certificate Form

1. The document is a medical certificate for an individual named Chandan Acharyee who is applying for a driver's license. 2. The examining doctor indicates that Chandan does not have any vision defects, can distinguish license plates from 25 meters away, does not have hearing problems or night blindness, and has no physical defects that would interfere with driving duties. 3. The doctor certifies that Chandan is medically fit to hold a driver's license based on the examination.

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68 views

Medical Certificate Form

1. The document is a medical certificate for an individual named Chandan Acharyee who is applying for a driver's license. 2. The examining doctor indicates that Chandan does not have any vision defects, can distinguish license plates from 25 meters away, does not have hearing problems or night blindness, and has no physical defects that would interfere with driving duties. 3. The doctor certifies that Chandan is medically fit to hold a driver's license based on the examination.

Uploaded by

DEEPAK
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM 1-A

4177777122
See rules 5(1),(3),7,10(a),14(d), and 18(d)] Appl No:4177777122 D:26-10-2022

MEDICAL CERTIFI ATE E


[To be filled in by a registered medical practitioner appointod for tho purposo by the State Government or porson
authorised in this behalf by the State Government referred to under sub section (3) of section 8]

CHANDAN ACHARJEE
1.Name of the applicant

2. Identification marks 1......


e*****s********************#*

3.
(a) Does the applicant, to the best of your jJudgment, suffer from any defect
of vision? If so, has it been corrected by suitable spectacles?
Yes/N6

distance of 25
(b) In your opinion, is he able to distinguish with his eye
metres in good day light a motor car number plate ?
sight at a
YsINo

(c) opinion, does the applicant suffer from a degree of deafness


In your Yes/N6
which would prevent his hearing the ordinary sound signals ?

Yes/N
(d) In your opinion, does the applicant suffer from night blindness ?

(e) Has the applicant any defect or deformity or loss of member which would Yes/No
interfere with the efficient performance of his duties as a driver? If so, give
your reasons in details.

(1) Optional
(a) Blood group of the applicant (if the applicant so desires that the AB+
information may be noted in his driving licence).

********* eeer*o*e**e
(b) RH factor of the applicant (if the applicant so desires that the
information may be noted in his driving licence).
Declaration made by the applicant in Form 1 as to his physical fitness is attached

Certificate of Medical Fitness


I certify that
(0) that I have personally examined the applicant Shri/SmtKum: CHANDAN ACHARJEE
(i) that while examining the applicant I have directed special attention to her/his distant vision;
(in) while examining the applicant, I have directed special attention to his/her hearing ability, the conditon of the arms,
legs, hands and joints of both extremities of the applicant;
(v) I have personally examined the applicant for reaction time, side vision and glare recovery, (applicable in case of
persons applying for a licence to drive goods carriage carying goods of dangerour or hazardous nature to
human life); and
() Applicant's colour vision has been tested using standard ishihara chart and the applicant has not been found
suffering from severe or total colour blindness.
And, therefore, I certify that, to the best of my judgment, he is medically fitnot fit to hold a driving licence.
The applicanttteotlia
is
notmedically fit to hold a licence for the following reasons:
Signature:
A 1. Name and designation of the of Meb al Officer / Practitioner
Dr Kisea! Ghosh
2. Regisfb:NmberatMedea oficer: 6 8139
P.G.D.D.M (WHO &MSU) C.C.E.I (RCP, LONDON)
Dip. Card (RCP, LONDON) P.G.D.C.ED. (RCP, LONDON)
hbnosh Diabetologist
P.O.D.DRM (RCP, LONDON) PGDAD.C.C (RCP, LONDON)
W.B.U.H.S.
o n

LONRON)
Medalist
c u m
Signature or thumb impression of the candidate
(RCP,

Physiian C.C.E

(CHANDAN ACHARJEE)
G o l d

Date General
3 . S(.
&MSU)
Hong

9HO
CaomAom
Note:-1. The medical Ofiaer Shall affix his signature over the
A
affixèd in such a photograph manner that part
of his signature (s.upon the photograph and part on the certificate.
2. Dumb persgis without deafness may be granted a valid certificate of driving licence for
non-trañsport vehicle.

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