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Form 1 (See Rule 5 (2) ) Application-Cum-Declaration As To Physical Fitness

This document contains an application for a physical fitness declaration required to obtain a driver's license. It includes details of the applicant such as name, date of birth, address, and identification marks. It also contains a declaration where the applicant must answer yes or no to questions regarding any medical conditions, disabilities, or impairments that could impact their ability to safely operate a motor vehicle. These include issues like epilepsy, eyesight, loss of limbs, colorblindness, night blindness, deafness, or other conditions. The applicant must sign declaring that their answers are true to the best of their knowledge.

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314 views

Form 1 (See Rule 5 (2) ) Application-Cum-Declaration As To Physical Fitness

This document contains an application for a physical fitness declaration required to obtain a driver's license. It includes details of the applicant such as name, date of birth, address, and identification marks. It also contains a declaration where the applicant must answer yes or no to questions regarding any medical conditions, disabilities, or impairments that could impact their ability to safely operate a motor vehicle. These include issues like epilepsy, eyesight, loss of limbs, colorblindness, night blindness, deafness, or other conditions. The applicant must sign declaring that their answers are true to the best of their knowledge.

Uploaded by

Shahruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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FORM 1

[See Rule 5(2)]


APPLICATION-CUM-DECLARATION AS TO PHYSICAL FITNESS

1. Name of the applicant : Jafar Ahmed Choudhury


2. Son/Wife/Daughter of : Jalal Ahmed Choudhury
3. Permanent address : Vill & P.O- Sutarkandi, P.S & Dist.- Karimganj, Assam
Pin- 788712

4. Temporary address :
Official address (if any)

5. (a) Date of birth : 25-10-2000 (20 years)


(b) Age on date of application

6. Identification marks (1) NIL

(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 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 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 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 any defect of 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 so 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 given above and the declaration
made therein are true.

(Signature or thumb impression of the 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 information relating thereto.
(2) This declaration is to be submitted invariably with medical certificate in Form 1 A.

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