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FORM 1
[See rule 5(2)]
APPLICATION-CUM-DECLARATION AS TO PHYSICAL FITNESS
Name of the applicant ce MAVIOT.... LAB,
Son/WHfE/Daughter of ARUN... SIVMGEL
Permanent address 492. WIVSYOTI Le
SALAVOHB R.. PUD 2
4, Temporary address
Official Addiess (if'any) 9 .
5. (a) Date of birth 13, NON..A9IS..
(b) Age on date of application 23, sen
6. Identification Marks () 2
(2).
Declaration,
(a) Do you suffer from epilepsy or
from sudden attacks of loss of
consciousness or giddiness from
any cause?
(6) Are you able to distinguish with
each eye (or if you have held a
driving license to drive a motor
vehicle for a period of not less
than five years and if you have
lost the sight of one eye after the
said period of five years and if
the application is for driving a
light motor vehicle other than a
transport vehicle fitted with an
outside mirror on the steering
wheel side)or with one eye, at a
distance of 25 meter in good day
light (with glasses, if worn) a
motor car number plate? &INo
(©) Have you lost either hand or foot
or are you suffering from any
defect of muscular power of
either arm or (ce) Do you suffer from night
blindness? Yes/ No
() Are you so deaf so as to be
unable to hear (and if the
application is for driving a light
motor, with or without hearing
aid) the ordinary sound signal? Yes/No~
(g) Do you suffer from any other
disease or disability. likely 10
cause your driving of a motor
Vehicle to be a source of danger
to the public, if so give details? Yes/No“
Thereby declare that, to the best of my knowledge and belief, the particulars given
above and the declaration made therein are true
1 ou’
Kew
(Signature or titumb impression of the Applicant)
Notes: - a) An applicant who answers “Yes” to any of the questions (a), (c),
(e), (, and (g) or “No” to either of the questions (b) and (d) should amplify his answers
with full particulars, and may be required to give further information re! lating thereto.
(2) This declaration is to be submitted invariably with medical
certificate in Form 1A.
