Form-1 [See Rule 5( 2)] Application-cum-declaration as to the physical fitness 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: (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 (or if you have held a driving licence to drive a motor vehicle 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 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 vehicle other than a transport vehicle fitted with an outside mirror on the steering wheel side) or with one eye, at a distance of 25 metres in good day light (with Yes/No glasses, if worn) a motor car number plate? (c) Have you lost either hand or foot or are you suffering from any defect or muscular power or Yes/No either arm or leg? (d) Can you readily distinguish the pigmentary Yes/No colours, red and green? (e) Do you suffer from night blindness? Yes/No (f) Are you so deaf as to unable to hear (and if the application is for driving a light motor Yes/No vehicle, with or without hearing aid) the ordinary sound signal? (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 Yes/No so, give details. I hereby declare that to the best of my knowledge and belief, the particulars given above and the declaration made therein are true. (Signature or thumb impression of the applicant) Note: (1) An applicant who answers 'Yes' to any of the questions (a), (c), (e), (f) and (g) or 'No' to either of the questions (b) and (d) Should amplify his answers 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
