FORM 1-A Medical Certificate [ To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person authorized in this behalf by the State Government referred to under sub-section (3) of Section 8) 1. Name of the applicant : 2. Identification Marks : (1) (2) 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 spectacle? 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 eye sight at a distance of 25 metres in good day light a motor car number place. 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 member which would interfere with the efficient performance of his duties as a driver? If so, give your reasons in details. Yes / No (g) Optional (a) Blood Group of the applicant (If the applicant so desires that the information may be noted in his driving licence). (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 : (i) I have personally examined the applicant Shri/Smt/Kum.. (ii) That while examining the applicant I have directed special attention to his/her distant vision; (iii) While examining the applicant, I have directed special attention to his/her hearing ability, the condition of the arms, legs, hands and joints of both extremities of the applicant; and (iv) 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 carrying goods of dangerous or hazardous nature to human life). And, therefore, I certify, that to the best of my judgment, he is medically fit/not fit to hold a driving licence. The applicant is not medically fit to hold a licence for the following reasons:- Signature 1. Name and Designation of the Medical Officer/Practitioner (Seal) 2. Registration Number of Medical officer Signature or thumb-impression of the candidate.. .. Space for passport size photograph of the applicant Date : Note:- The Medical officer shall affix his signature over the photograph affixed in such a manner that part of his signature is upon the photograph and part on the certificate.
