Driving Licence Medical Report Form - Ndls

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Driving Licence Medical Report Form
To drive you must meet certain medical fitness standards. For this purpose vehicles are classed as Group 1 and Group 2.
If you are applying for a vehicle in both Groups (See note 2 overleaf) please tick Group 1 and 2 on this form. Where an applicant
meets the medical criteria for Group 2 vehicles, they will automatically meet the medical criteria for Group 1 vehicles.
Driver number
First name(s)
Surname
Address 1
Address 2
Town/City
County
Postcode
Date of birth
Day
Month
Year
PPSN
(Please X the appropriate box)
I wish to undergo a medical examination on foot of my application for a learner permit/driving licence as required
by the Road Traffic Acts. (See note 1 overleaf).
My application is for a driving licence/learner permit as a driver of a Group 1
or Group 2
vehicle.
(See note 2 overleaf).
Has your most recent licence/permit been revoked or have you been advised
by a medical professional to cease driving for a period?
Yes
No
If yes please advise reason__________________________________________
If you have in the past suffered or currently suffer from epilepsy, please indicate the date of your last seizure. Where this date
is less than 12 months from today it is essential that you fall into the category of an exceptional case (available to Group one
drivers only) that allows you drive earlier than this. To be certified as fit to
drive your case will need to be reviewed by a consultant neurologist.
Day
Month
Year
Signature
(To be signed in the presence of your Medical Practitioner)
Day
Month
Year
This form must be submitted to National Driver
Licence Service with an application for a driving
VEHICLES IN
licence/learner permit within one month of its
GROUP 1
completion by a Medical Practitioner.
AND GROUP 2

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