FORMS
[See Rule 2(b)]
FORM – I
[See rules 5, 7, 10(a) and 14(d)]
Medical Certificate in respect of an applicant for obtaining a Learner’s License/Driving License of
renewal of a driving license.
Space for
PART I photograph of
TO BE FILLED IN BY THE APPLICANT the size 5 cm
by 6 cms.
1. Name of 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 (which glasses,
if worn)? Yes/No…………..
c. Have you lost either head 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 colours red or green? Yes/No………….
e. Do you suffer from night blindness? Yes/No……………
f. Are you so deaf so as to be unable to hear (and if the application is for a driving a light motor vehicles
with or without hearing aid) the ordinary sound and signal? Yes/No…………
g. Do you 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? Yes/No……….
I hereby declare that to the best of my knowledge and belief, the particulars given above and the
declaration made therein are true.
Signature of the Applicant.
Note:- An applicant who answers ‘YES’ to any of the questions (a), (c), (f), and (g) or ‘NO’ to either of the
questions (b) and (d) should amplify his answer with full particulars and may be required to give further
information relating thereto.
FORM – IA
Medical Certificate
(To be filled in by a registered medical practitioner appointed for the purpose by the State
Government or person authorised in this behalf by the State Government 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 effect his 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 suitable 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 prevent his hearing the ordinary
sound signal? 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. If so, give your reasons in details ? Yes/No………….
h. Does he show any evidence or being addicted to excessive use of alcohol, tobacco or
drug? Yes/No……….
i. Does he suffer from attacks or loss of consciousness from any cause? Yes/No………
j. Is he able to distinguish with each eye at a distance of 25 metres in good daylight a motor
plate ? Yes/No…………
k. Is he suffering from any defect in movement control or muscular power of either arm or limb?
Yes/No…………
l. What is the height of the applicant? Do you consider that his height will be
disadvantageous or 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 regards :
(i) Bodies health …………………………….
(ii) Eye sight ………………………………….
(iii) Mental ability and …………………………
(iv) Hearing ability……………………………..
p. Blood Group of the applicant : ……………………..…………………
q. RH factor of the applicant……………………………………………..
I have examined the applicant. I am on the opinion that he is not fit to hold driving license on the
following reasons:
……………………………………………………………………………………………………………
………………………………………………………………………
Signature ………………………………………
Name & Designation of the Medical Officer
……………………………………………………
……………………………………………………
Dated …………………
I Certify that I have personally examined the applicant………………………..………….……
I also certify that while examining the applicant I have directed special attention to the distance 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 license.
Signature……………………………………
(S E A L)
Signature of the Candidate……………….…………….
Note(1) The medical Officer shall affix his signature over the photograph in 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 I notified with
reference to sub-section (3) of section 8 of the Motor Vehicle Act, 1988 and the serial
number in the List where his name appears.
