1.Name of the applicant 2. Son Wife Daughter of 3.Permanent Address 4.Temporary AddressOfficial Address (If any) 5.(a) Date of Birth (b) Age on Date of application 6. Identification Mark (!) Declaration(a) Do you suffer from epilepsy or from sudden attack of loss of consciousness or giddiness from any cause? NoYes (c) Have lost either hand or foot or are you suffering from any defects in movement, control or muscular power of either arm or leg? (d) Can you readily distinguish the pigmentary colors, red and green? (b) Are you able to distinguish with each eye (or if you have held a driving license to drive a motor vechile for a period of not less than five years and if you have lost, the sight of one eye after the said period of five years and if the application is for driving a light motor vechile other than a transport vechile fitted with an outside mirror on the steering wheel side) or with one eye, at a distance of 25 meters in good day light (with glasses, if worn) a motor car number plate? CENTRAL MOTOR VEHICLES RULES, 1989 [See Rule 5 (2)] APPLICATION - CUM - DECLARATION AS TO PHYSICAL FITNESS Your age at the time of application Published on National Portal of India (india.gov.in) Government of OrissaCommerce & Transport DepartmentForm1 I hereby declare that, to the best of my knowledge and belief, the particular given above and the declaration made therein are true. Note:- (1) An applicant who answer "Yes" to any of the question (a), (c), (e), (f) , (g) or "No" to either of the question (b) ,(d) should imply his answer 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 Published on National Portal of India (india.gov.in) Signature of the Applicant(e) Do you suffer from night blindness? (f) Are you so deaf so as to be unable to hear (and if the application is for driving a light motor vehicle, with or without hearing aid) the ordinary sound signal? (g) Do suffer from any other disease or disability likely to cause your Driving of a motor vehicle to be source of danger to the public, if so, give details. NoYes
