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Form 1 A

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18 views

Form 1 A

Docs

Uploaded by

bharat2595
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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FORM 1-A

[see rule 5 (1), (3), 7, 10 (a), 14 (d) and 18 (d)]

Medical Certificate
[Form I (A) should be filled by a registered medical practitioner who is at least MBBS and
above, by the State Government referred to under sub-section (3) of section 8.]
1. Name of the applicant : ………………………………………………………...........
2. Identification marks : ………………………………………………………………
Declaration:
3. (a) Does the applicant, to the best of your judgment, suffer from any
defect of vision? If so, has it been corrected by suitable Spectacles? Yes / No
(b) Can the applicant, to the best of your judgment, readily distinguish
the pigmentary colours, red and green? Yes / No
(c) In your opinion, is he able to distinguish with his eyesight at a
distance of 25 meters in good day light a motor car number plate? Yes / No
(d) In your opinion, does the applicant suffer from a degree of deafness
which would prevent his hearing the ordinary sound signals? Yes / No
(e) In your opinion, does the applicant suffer from night blindness?
Yes / No
(f) Has the applicant any defect or deformity or loss of memory which
would interfere with the efficient performance of his duties as a driver? If
so, give your reasons in detail Yes / No

Optional
(a) Blood Group of the applicant (if the applicant so desires that the
information may be noted in his driving license),
(b) RH factor of the applicant (if the applicant so desires that the
information may be noted in his driving license).

Declaration made by the applicant in Form-1 as to his physical fitness is attached.


I certify that I have personally examined the applicant …..………..………………………………
I also certify that while examining the applicant, I have directed special attention to distant
vision and hearing ability. The condition of the arms, legs, hands and joints of both
extremities of the applicant and to the best of my judgement he/ she is medically fit / not fit*
to hold a driving license.
*The applicant is not medically fit to hold a license for the following reasons:

Signature
1. Name and Designation of medical
Officer / Practitioner

(Seal)
2. Registration Number of Medical
Officer

Note : The Medical Officer shall affix his signature over the photograph affixed in a manner
that part of his signature is upon the photograph and part on the certificate.
Form downloaded from www.myrto.in

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