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Form 1 PDF

1. This document is an application form for determining an applicant's physical fitness for driving. 2. The form requests information about the applicant such as name, address, age, identification marks, and whether they have any conditions that could impact their ability to drive such as epilepsy, loss of vision, loss of limbs, hearing problems, or other disabilities. 3. The applicant must declare whether they have any of these conditions and sign the form, with the understanding that additional information may be required if they answer yes to certain questions about their health.

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Herbert Anision
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97 views

Form 1 PDF

1. This document is an application form for determining an applicant's physical fitness for driving. 2. The form requests information about the applicant such as name, address, age, identification marks, and whether they have any conditions that could impact their ability to drive such as epilepsy, loss of vision, loss of limbs, hearing problems, or other disabilities. 3. The applicant must declare whether they have any of these conditions and sign the form, with the understanding that additional information may be required if they answer yes to certain questions about their health.

Uploaded by

Herbert Anision
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM 1

APPLICATION-CUM-DECLARATION AS TO PHYSICAL FITNESS


[See Rule 5(2)]
1. Name of the Applicant .....................................................................
.....................................................................
2. Son/Wife/Daughter of .....................................................................
.....................................................................
3. Permanent address .....................................................................
.....................................................................
.....................................................................
4. Official / Temporary .....................................................................
address (if any) .....................................................................
5. Date of birth Date.............. Month............ Year ...............
Age on date of application .....................................................................
6. Identification marks (1).................................................................
(2).................................................................
DECLARATION :
(a) Do you suffer from epilepsy, or from sudden attacks of loss of consciousness or
giddiness from any cause ? Yes/No.
(b) 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 motor vehicle other than a transport vehicle fitted with an outside mirror
on the steering wheel side) or with eye, at a distance of 25 metres in good day light
(with glasses, if worn ) a motor car number plate? Yes/No.
(c) Have you lost either hand or foot or are you suffering from a defect or muscular
power of either arm or leg ? Yes/ No.
(d) Can you readily distinguish the pigmentary colours, red and 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 hearing aid) the ordinary sound signal ? Yes/No
(g) Do you suffer from any other disease or disability likely to cause your driving of a
motor vehicle to be a source of danger to the public, if so, give details. Yes/No
I hereby declare that to the best of my knowledge and belief, the particulars gives above
and the declaration made therein are true.
(Signature or thumb impression of the application)
Note : (1) 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 information relating
thereto.
(2) This declaration is to be submitted invariably certificate in Form 1-A.

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