FORM 1-A llllllllll []l]ltill[
46()56A5424
[See rules 5(1),(3),7,10(a),14(d), and 18(d)] Application Date:
MEDICAL CERTIFICATE
purpose by the State Government or person
lTo be filled in bY a registered medical practitioner appointed for the
Lu(horiseO in this behalf bY the State Government referred to under sub section (3) of section 8l
PARSHU RAM
1.Name of the aPPlicant
1 A-SonMife/Daughter of SH PANNA LAL
178, BIJNA, POST OFFICE BIJNA, 284206
1 B-Permanent address
1C-Date of birth 04-07-1 968
2. ldentification marks 1............,.
a,2
"' 1"; Do". the applicant, to the best of
your jiliibiiiiiiit, suttdi from-any defect
corrected by suitable spectacles ?
'es/No t/
of vision? lf so, has it been
(b)'otln your opinion, is he able to distinguish with his eye sight at a distance
V
Yes/N
' iS meters in good day light a motor car number plate ?
(c) ln your opinion, does the applicant suffer from a degree of deafness
' '
which would prevent his hearing the ordinary sound signals ? veriruJ/
(d)lnyouropinion,doestheapplicantsufferfromnightblindness? Yes/No
t/
or loss of member which would
' Has the applicant any defect or deformity
(e)
interfere with the efficient performance of his duties as a driver? lf so,
give
vesrN/
your reasons in details.
(f) Optional
'' (if the applicant so desires that the
1a) Alood group of the applicant
'' informition may be noted in his driving licence)'
(b)RHfactoroftheapplicant(iftheappiicantS0desiresthatthe
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) that I have personally examined the applicant Shri/SmUKum:PARSHU RAM
(ii) that while examining the applicant I have directed special attention to her/his distant vision;
ability, the conditon of the arms,
(iii) while examining tne"appricairi, L nave directed special attention to his/her hearing
legs, hands and joints of both extremities of the applicant; case of
-' I have personally
(iv) the applicant for reaciion time, side vision and glare recovery, (applicable in
' p"iron. for a licence to diive goods carriage carrying goods of dangerour or hazardous
applyin! "*"rin"O
nature to
human life); and
ishihara chart and the applicant has not been found
' ' Applicant,s colour vision has been tested using standard
(v)
suffering from severe or total colour blindness"'
hold a driving licence'
nno, ineretSre, I certify that, to the best of my judgment' he is medically FiuUnFitto
TheapplicantisFiUUnFittoholdalicenceforthefollowingreasons:
siqnature,o"y
Signature LhThr-yr 0 P!
1. Name ancl designation of the of / Practitioner
(Seal) W*-f z )lq
2. Registration Number of Medical O
CEl{TRE.
r4-Z-srl1arr-E7- DR.LATAFATATi
(MBBs)
Signature or thumb impression of the candidate NEW DEIHI
Ari ( PARSHU RAM )
Date
(MBBSI
in such a manner that part
-i. ,n" meoiqp{rffii6rl affix his sienature.ov:1t!: P3llsj,X{*lffixed
of his signi[ure i. up6n the photograph and part on the certificate.
of driving licence for
Z. OumO pJr.on. without deafness miay'be granted a valid certiflcate
non-transport vehicle.
