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Jaswinder Singh Surjit Singh Father's Name: Appl No:3228874623 Dt:22-08-2023

This document contains an application for a commercial motor vehicle driver's license. It includes: 1) Personal information of the applicant such as name, age, address, identification marks. 2) A declaration where the applicant answers yes or no to questions regarding any medical conditions like epilepsy, eyesight, loss of limbs, hearing that could impact their ability to safely drive a commercial vehicle. 3) A statement by the applicant declaring that to the best of their knowledge, all information provided is true. A note explains that additional details may be required if any questions are answered "Yes" or "No to eyesight questions.

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12 views

Jaswinder Singh Surjit Singh Father's Name: Appl No:3228874623 Dt:22-08-2023

This document contains an application for a commercial motor vehicle driver's license. It includes: 1) Personal information of the applicant such as name, age, address, identification marks. 2) A declaration where the applicant answers yes or no to questions regarding any medical conditions like epilepsy, eyesight, loss of limbs, hearing that could impact their ability to safely drive a commercial vehicle. 3) A statement by the applicant declaring that to the best of their knowledge, all information provided is true. A note explains that additional details may be required if any questions are answered "Yes" or "No to eyesight questions.

Uploaded by

mother22gg
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Appl No:3228874623 Dt:22-08- CMV FORM 1

2023 [See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : JASWINDER SINGH

2. Father's Name : SURJIT SINGH

3.Permanent address :
NABHA,PATIALA,PB
147202

4.Temporary address :
Official address (if any)
NABHA,PATIALA,PB
147202

5. (a) Date of birth : 16-02-1973


(b) Age on date of application : 50 years
6. Identification marks :

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of Yes/No


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 application Yes/No
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?

(c) Have you lost either hand or foot or are you suffering Yes/No
from any defect in movement, control or muscular power of either
arm or leg ?

(d) Do you suffer from night blindness ? Yes/No

(e) 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
hearing aid) the ordinary sound signal ?

(f) Do you suffer from any other disease or disability likely to Yes/No
cause your driving of a motor vehicle to be a source of 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 therein are true.

Signature or thumb impression of the applicant


( JASWINDER SINGH )

Note : - (1) An applicant who answers 'Yes' to any of the questions (a),(c),(d), (e) and (f) or 'No' to
either
of the questions (b) 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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