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FORM 1 RULE 5 (2)

The document is an application-cum-declaration for physical fitness by Satish Krishn Kadam, dated June 28, 2021. It includes personal details such as name, address, date of birth, and a series of health-related questions, all of which he answered 'No'. The declaration confirms that the information provided is true to the best of his knowledge.

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SATISH KRISHNA KADAM
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8 views

FORM 1 RULE 5 (2)

The document is an application-cum-declaration for physical fitness by Satish Krishn Kadam, dated June 28, 2021. It includes personal details such as name, address, date of birth, and a series of health-related questions, all of which he answered 'No'. The declaration confirms that the information provided is true to the best of his knowledge.

Uploaded by

SATISH KRISHNA KADAM
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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Appl No:1995512821 Dt:28-06-2021 CMV FORM 1

[See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : SATISH KRISHN KADAM

2. Father's Name : KRISHNA RAMU KADAM

3.Permanent address : 447


BILUR JATH
Jat,Sangli,MH
416404

4.Temporary address : 447


Official address (if any) BILUR JATH
Jat,Sangli,MH
416404

5. (a) Date of birth : 26-07-1991


(b) Age on date of application : 29 years
6. Identification marks :

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of 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 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 No
from any defect in movement, control or muscular power of either
arm or leg ?

(d) Do you suffer from night blindness ? 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 No
hearing aid) the ordinary sound signal ?

(f) Do you suffer from any other disease or disability likely to 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


( SATISH KRISHN KADAM )

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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