(See rule 2(b)) FORM - 1 (see rules 5,7,10(a) and 14(d)) Medical Certificate in respect of an applicant for obtaining a learner's licence/driving licence or renewal of a driving licence. PART - I Space for photograph of the size five centimeters by six centimeters (TO BE FILED IN BY THE APPLICANT) 1. Name of the applicant 2. Son/wife/daughter of 3. Permanent address 4. Temporary address Official address (if any) 5. Date of birth 6. Identification marks: (1) (2) Declaration as to physical fitness to be given by the applicant: (a) Do you suffer from epilepsy,or from sudden attacks of loss of consciousness or giddiness from any cause ? Yes/No (b) Are you able to distinguish with each eye at a distance of 25 meters in good day light (with glasses, if any) ? Yes/no (c) Have you lost either hand or foot or are you Suffering from any defect in movement, control or muscular power of either arm or leg ? Yes/No (d) Can you readily distinguish the pigmentary (e) Colours, red and green ? Yes/No (e) Do you suffer from night blindness ? Yes/No (f) Are you deaf 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 ? Yes/No (g) Do you suffer from any other disease or Disability likely to cause your driving of a Motor vehicle to be a source of danger to the public, if so, give details. Yes/No I hereby declare that to the best of knowledge and belief, the particulars given above and the declaration made herein are true. Signature of the applicant Note: An applicant who answer 'Yes' to any of the questions(a), (c), (e), (f) and (g) or 'No' to either of the question (b) and (d) should amplify his answer with full particulars, and may be required to give further information relating thereto. PART- II (To be filled in by a registered medical practitioner appointed for the purpose by the State Govt. or person authorised in this behalf by the State Govt. referred to under sub-section (3) of section 8 ) 1. Name of the applicant 2. Son/Wife/Daughter of 3. Permanent address 4. Temporary address 5. Date of birth 6. Identification Marks (1) (2) 7.(a) Is the applicant to the best of your judgement subject to epilepsy, vertigo, or any mental ailment likely to affect this driving efficiency ? Yes/No (b) Does the applicant suffer from any heart or Lung disorder which might interfere With the performance of his duties As a driver ? Yes/No (c) Is there any defect of vision ? If so, has It been corrected by dsuitable spectacle ? Yes/No (d) Can the applicant readily distinguish the Pigmentary colours, red and green ? Yes/No (e) Does the applicant suffer from a degree of Deafness which would prevent him Hearing the ordinary sound signals ? Yes/No (f) Does the applicant suffer from night blindness ? Yes/No (g) Has the applicant any deformity or loss of member which would interfere with the efficient performance of his duties as a driver ? If so, give your reason in detail. Yes/No (h) Does he show any evidence of being addicted to excessive use of alcohol, tobacco or drug ? Yes/No (i) Does he suffer from attacks of loss of consciousness from any cause ? Yes/No (j) Is he able to distinguish with each eye at a distance of 25 meters in good day light a motor car number plate ? Yes/No (k) Is he suffering from any defect in move- ment control or muscular power if either arm or limb ? Yes/No (l) What is the height of the applicant ? Do you consider that his height will be disad- vantageous for him to have a clear vision of the road while driving ? Yes/No (m) Is he a mentally ill person ? Yes/No (n) Does he suffer from any other disease or disability likely to cause his driving a motor vehicle a source of danger to the public ? Yes/No (o) Is he in your opinion generally fit as regard (i) bodily health (ii) eye sight (iii) mental ability; and (iv) hearing ability ? Yes/no (p) Blood group of the applicant ............ (q) RH factor of the applicant ............ I have examined the applicant. I am of the opinion that he is not fit to hold a Driving Licence for the following reasons :- Date: Signature Name and Designation of the Medical Officer. I certify that I have personally examined the applicant. I also certify that while examining the applicant I have directed special attention to the distant vision and hearing ability, the condition of the arms, legs, hands and joints of both extremities of the candidate and he is medically fit to hold a driving licence. Date Signature (Seal) Name and Designation of the Medical Officer. Signature of the candidate NOTE: (1) The Medical Officer shall affix his signature over the photograph is such a manner that part of his signature is upon the photograph and part on the certificate. (2) Particulars of the Gazette where the Medical Officer's appointment is notified with reference to sub-section (3) of Section 8 of the Motor Vehicles Act, 1998 and the serial number in the list where his name appears.
