MEDICAL FORM
REPUBLIC OF KENYA
MEDICAL ASSESSMENT CERTIFICATE FOR DRIVERS/PROSPECTIVE
DRIVERS/DRIVING INSTRUCTORS
Name……………………………………………………………………………………………
Date…………………………………..
Sex M F Age…………………………………………
License Class……………………………….
Name of Hospital_________________________________________________
County_________________________________________________________
SECTION A: VISUAL ASSESMENT
The applicant visual condition is Suitable Not suitable
Reasons (if not suitable)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………
Examined By………………………………………………………………………
Signature…………………………… Date………………
SECTION B: HEARING ASSESSMENT
The applicant visual condition is Suitable Not suitable
Reasons (if not suitable)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………
Examined By………………………………………………………………………
Signature…………………………… Date………………
1
SECTION C: GENERAL BODY ASSSESSMENT
The applicant general body condition is Suitable Not suitable
Reasons (if not suitable)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Examined By………………………………………………………………………
Signature…………………………… Date………………
SECTION D: OVERALL REMARKS
Meets the relevant medical criteria - Fit to drive
Does not meet the relevant medical criteria - Not fit to drive
Remarks…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
Medical Practitioners Name………………………………………………………………….
Signature…………………………… Date………………
Official Stamp
2
APPLICATION FORM FOR DRIVING INSTRUCTOR LICENSE
APPLICATION FOR DRIVING INSTRUCTOR LICENSE FORM
FOR OFFICIAL USE
Application Number
PART 1- APPLICANT (To be completed by applicant)
A. CANDIDATES’S INFORMATION
Details of candidate
Title: Surname: Forename
Address: Post code Town
Date of birth: E-mail address
Mobile No
Driving License No: Date of issue
Driving Categories
B. CATEGORIES OF DRIVING INSTRUCTOR LICENSE
Test category (please tick the type of vehicle you wish to be licensed to instruct)
A1 (Moped max 50 cc) A2 (Light motorcycle max 125 cc)
A3 (Heavy motorcycle exceeding 125 cc/ Motorcycle Taxi, Couriers and three-wheelers)
B (Light vehicle max gross weight 3500kgs)
B Professional (Light vehicle max gross weight 3500kgs)
C1 (light truck with gross weight exceeding 3500 kg and max 7500)
C (Heavy truck gross weight exceeding 7,500 kg) CE (Heavy truck with trailer)
CD (Heavy Goods Vehicle for Transportation of Hazardous Materials; Gross weight
exceeding 7,500 kg)
3
D1 (Light bus maximum 14 passengers in addition to Driver)
D2 (Between 14-32 passengers)
D3 (33 passengers and above)
E (Special Professional Drivers’ License)
F (Special Drivers’ License for Persons with Disability
G (Construction, Industrial and agricultural vehicles)
C. DECLARATION
I declare that I have read all the answers I have given to the questions in this application and
that the answers given by me are complete, true and correct in every detail.
I understand that if I have stated anything that is false or misleading, the license granted to
me as a result of this application will be absolutely void and have no legal effect whatsoever.
I understand that I may be prosecuted for giving or stating facts or misleading information or
documents.
I also declare that the information I have given on my fitness to drive, is to the best of my
knowledge, true and correct.
Applicants’ signature
Date
