APPLICATION NUMBER : S/92447/2014

TABLE ID : 2
DATE : 04-09-2014
Form 9
[See Rule 18(1)]
FORM OF APPLICATION FOR THE RENEWAL OF DRIVING LICENCE
To,
The Licensing Authority,
ALA, KOZHIKODE
Affix Your
Recent
Passport Size
Photo

I, hereby apply for the renewal of my driving licence which is attached and particulars of
which are as follows

: 11/4638/1994
: 27-07-1994

Licensing authority by which the licence was issued

ALA, KOZHIKODE

Licensing authority by which the licence was last renewed :

ALA, KOZHIKODE

R
TM

Date Of Issue

EN

License No

Name of the Applicant

I

J U

C h

EP

Name of the Guardian

Class of vehicles authorised to be driven :

LE
S

1 : MOTOR CYCLE WITH GEAR

2 : LIGHT MOTOR VEHICLE

Date of expiry of licence to drive :

H
IC

(i) Transport vehicle : --

VE

(ii) Vehicles other than transport vehicle : 26-07-2014

Present Address
AYITTADIYIL

MAYANAD

Temporary Address

O
TO

CALICUT
673008

If the licence is not attached, reasons why it is not available?

If the licence was not renewed within thirty days of the date of expiry, reasons for delay

LA

The renewal of licence has not been refused by any licensing authority
I have not been disqualified for holding or obtaining a driving licence. My licence has not been revoked

I enclose a Medical Fitness Certificate Form 1A

ER

I enclose three copies of my recent photographs(5 cms by 6 cms)

I have paid the fee of Rs : 200+50+50=300/I hereby declare that to the best of my knowledge and belief the particulars given above are true
.............................................
Signature or thumb impression of applicant

IT Services: NIC Kerala

APPLICATION NUMBER : S/92447/2014

TABLE ID : 2
DATE : 04-09-2014

Form - 1

APPLICATION CUM DECLARATION AS TO THE PHYSICAL FITNESS

See Rule 5(2)
Name of Applicant

RIJU A C

Son / Wife / Daughter of

Chandrasekharan

Date of Birth

30/05/1975

Age as on date of application

39

Identification Marks

Affix Your
Recent
Passport Size
Photo

:
1:

Present Address

Temporary Address / Official Address

R
TM

AYITTADIYIL

EN

2:

MAYANAD
CALICUT

EP

673008
DECLARATION

YES / NO

LE
S

(a) Do you suffer from epilepsy or from sudden attacks of loss of consciousness or giddiness from any cause?

(b) Are you able to distinguish with each eye (or if you have held a driving licence 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
YES / NO

H
IC

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 metres in good daylight (with glasses,if worn) a motor car

VE

number plate?

(c) Have you lost either hand or foot or are you suffering from any defect of muscular power of either arm or leg?

YES / NO

O
TO

(d) Can you readily distinguish the pigmentary colours,red & green?

YES / NO

(e) Do you suffer from night blindness?

YES / NO

(f) Are you so deaf as to be unable to hear (and if the application is for driving a light motor vehicle,with or without
YES / NO

LA

hearing aid) the ordinary sound signal?

(g) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of
YES / NO

ER

danger to the public ,if so,give details?

I hereby declare that to the best of my knowledge and belief,the particulars given above and the declaration made
there in are true
.............................................
Signature or thumb impression of applicant
NOTE:
1) An applicant who answers 'Yes' to any of the questions (a),(c),(e),(f) 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 of information relating thereto
2) This declaration is to be submitted invariably with medical certificate in the form 1
IT Services: NIC Kerala

APPLICATION NUMBER : S/92447/2014

TABLE ID : 2
DATE : 04-09-2014

Form 1-A
Medical Certificate
[See Rules 5,7,10(a),14(d) and 18(d)]

[To be in filled by a registered medical practitioner appointed for the purpose by the State Government or person authorised
in this behalf by Uthe State Government referred to,under sub-section(3) of Section8]

Name of Applicant

RIJU A C

Chandrasekharan

Date of Birth

30/05/1975

39

Identification Marks

EN

Age as on date of application

Affix Your
Recent
Passport Size
Photo

Son / Wife / Daughter of

:
1:

R
TM

2:

(a) Does the applicant to the best of your judgement suffer from any defect of vision.If so,has it been corrected

Yes / No

EP

by suitable spectacle ?

Yes / No

(b) Can the application to the best of your judgement readily distinguish the pigmentary colours,red and green?

LE
S

(c) In your opinion ,is he/she able to distinguish with his/her eyesight at a distance of 25 metres in good day
light a motor car number plate.

Yes / No

H
IC

(d) In your opinion does the applicant suffer from a degree of defness which would prevent his hearing
the ordinary sound signals?

Yes / No

VE

(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 efficient performance
Yes / No

O
TO

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

Optional

(a) Blood Group of the applicant (if the applicant so desires that the information may be noted in his driving licence)

LA

(b) RH factor of the applicant (if the applicant so desires that the information may be noted in his driving licence)
I certify that :-

(i) I have personally examined the applicant Shri. / Smt. / Kum. RIJU A C

ER

(ii) while examining the applicant I have directed special attention to his/her distant vision;
(iii) while examining the applicant ,I have directed special attention to his/her hearing ability,the condition of the

arms , legs,hands and joints ofboth extremities of the applicant and

(iv) I have personally examined the applicant for reaction time,side vision and glare recovery (applicable in case of
persons applying for licence to drive goods carriage carrying goods of dangerous or hazardous nature to human life).
And,therefore,I certify that ,to the best of my judgment, he/she is medically fit /not fit to hold a driving licence
The applicant is not medically fit to hold a licence for the following reasons:-

1. Name and designation of the Medical Officer/Practitioner

2. Registration number of Medical Officer
IT Services: NIC Kerala

Signature

APPLICATION NUMBER : S/92447/2014

TABLE ID : 2
CERTIFICATE FOR VISUAL STANDARDS FOR DRIVING

DATE : 04-09-2014

( To be filled in by Registered Ophthalmology )

Name of Applicant

RIJU A C

Son / Wife / Daughter of

Chandrasekharan

Date of Birth

30/05/1975

Age as on date of application

39

Identification Marks

Affix Your
Recent
Passport Size
Photo

:
1:

EN

2:

R
TM

I have examined Shri/Smt. RIJU A C aged 39 and his/her visual standards are as follows:
I. Visual Acuity
B

Sph

Unaided

Corrected

Cyl

Axis

C
Binocular
Corrected

EP

Visual Acuity

RE

LE
S

LE

H
IC

II. Night blindness ............................................

VE

III. Squint............................................................

IV.Field(Degree) Horizontal............................................Vertical............................................

O
TO

V.Fundus:......................................................... RE ...........................................................LE
Any other significant ocular morbidity .................................................................................

Candidate is Fit/Unfit to drive a Category l / ll vehicle .........................................................

LA

Unfit due to criteria .......................................... mentioned above .......................................

(Category-I means Non Transport Vehicles which include Motor Cycles, Motor Cars, etc.specified as such in Central Goverment

ER

Notification No.S.O.1248(E) dated 5th November 2004 as non-transport vehicles)

(Category-II means Transport vehicles which include Autorickshaws, Taxis, Stage Carriages, contract Carriages, goods carriages,
Private Service Vehicles etc. specified as such in the said Notification.)

Signature of candidate:
Place :
Date : 04-09-2014

IT Services: NIC Kerala

Signature of Ophthalmologist
Seal

Certificate to be issued by an Ophthalmologist with a registered post graduate qualification in Ophthalmology.

The seal should contain the name, qualifications and register number of the Ophthalmologist.
Visual Standards criteria for driving
Category I: Non-Transport Vehicles- includes Motor Cycles (MC), Owner driven Light Motor Vehicles (LMV)
(Vehicles not fitting criteria for category ll)
Category II: Transport Vehicles- Heavy Motor Vehicles (HMV), Commercial Passenger carrying vehicles, Goods carriers
(Any Category requiring issuance of a Badge)
I. Visual Acuity

1A. Unaided

EN

Category I: Binocular unaided visual acuity of 3/60 or better

R
TM

1B. Corrected
Category I : Worse eye corrected visual acuity of 6/60 or better
Category II: Worse eye corrected visual acuity of 6/12 or better

1C. Binocular Corrected

EP

Category I: Binocularly, with glass correction, the candidate should be able to read 6/12 or better.

Category II: Binocularly, with glass correction, the candidate should be able to read 6/9 or better.

LE
S

II. Night blindness *

Presence of night blindness is not acceptable for both category II and I

III. Manifest Squint

H
IC

*This being a symptom is recorded as reported by the patient.

Category I: Squint with visual acuity as in criteria I acceptable.

VE

Category II: Any squint is unacceptable for Category II

IV. Field

O
TO

Binocular field checked by confrontation methos

Category I: Horizontal field of vision of 120 degrees and vertical of 40 degrees

Category II: Horizontal field of vision of 180 degrees and vertical of 40 degrees
V. Fundus

LA

Undialted fundus examination unless otherwise indicated.To be recorded as WNL(Within noramal Limits) or any specific
pathology noted.

Any Pathology that can affect night vision, field, acuity should be investigated and the clination should decide on fitness.

ER

Colour vision problems by itself are not impediment to driving.

IT Services: NIC Kerala