l
FORM 1.A illllllililil illillll I]l
[See rules 5(1],(3),7,10(a],14(d], and 18{dN Application Date:
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 8l
1.Name of theapplicant ' SANJEEV
1A-Son/Wife/Daughter of : BALJEET
1B-Permanent address : HOUSE NO-510, - azad vihar khora colony Khora Gaon, Khora
Ghaziabad Ghaziabad Uttar Pradesh. 201309
1C-Date of birth 01-01-1984
me Bhafti
2. Identification marks 1:+]1 sl,ll9/#.
3.(a) Does 2..................
the applicant, to the best of your judgment, suffer from any d
of vision? lf so, has it been corrected by suitable spectacles ? YesiNd"
(b) ln your opinion, is he able to distinguish with his eye sight at a distance
of 25 meters in good day light a motor car number plate ? -:leflNo
(c) ln your opinion, does the applicant suffer from a degree of deafness
which would prevent his hearing the ordinary sound signals ?
Yes/lrle--
(d) ln your opinion, does the applicant sufferfrom night blindness ?
Yes/lrlcr"
(e) Has the applicant any defect or deformity or loss of member which would
interfere with the efficient performance of his duties as a driver? lf so, give /'
your reasons in details. Yes/No-./-
(f) Optional
(a) Blood group of the applicant (if the applicant so desires that the
information may be noted in his driving licence). Unknown
(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) that I have personally examined the applicant Shri/Smt/Kum:SANJEEV
(ii) that while examining the applicant I have directed special attention to her/his distant vision,
(iii) while examining the applicant, I have directed special attention to his/her hearing ability, the conditon of the arms,
legs, hands and joints of both extremities of the applicant;
(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 dangerour or hazardous nature to
human life); and
(v) Applicant's colour vision has been tested using standard ishihara chart and the applicant has not been found
suffering from severe or total colour blindness".
And, therefore, I certify that, to the best of my judgment, he is medically FiUUnFitto hold a driving licence.
The applicant i s Fitto hold a licence for the following reasons : -
Signature :
1. Name and designation of the of lt/edical Officer / Practitioner
(Seal)
2. Registration Number of Medical Officer:
'
'":;t;'"1
Signature or thumb impression of the candidate
Date ( SANJEEV )
Note : -1. 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.
2. Dumb persons without deafness may be granted a valid certificate of driving licence for
non-transpoft vehicle.
