Form 1-A - Medical Certificate printable pdf download

Form 1-A - Medical Certificate

FORM 1-A

[See Rules 5(1), (3), (7), 10(a), 14(d) and 18(d)]

MEDICAL CERTIFICATE

Space for

passport size

photograph

[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. Identification marks

(1)

……………………………………………………………………..

(2)

……………………………………………………………………..

Declaration:

(a) Does the applicant, to the best of your judgment, suffer from any defect of vision? If so, has

it been corrected by suitable Spectacles?

Yes/No

(b) Can the applicant, to the best of your judgment, readily distinguish the pigmentary colours,

red and green?

Yes/No

day light a motor car number plate?

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

Yes/No

efficient performance of his duties as a driver? If so, give your reasons in detail.

(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.

Form 1-A - Medical Certificate