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FORM 1

This document is an application-cum-declaration form for physical fitness required for driving license applicants. It collects personal information and poses a series of health-related questions to assess the applicant's fitness to drive. The form also includes instructions for applicants who may need to provide additional details based on their responses.

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onlinecentershahpur
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9 views

FORM 1

This document is an application-cum-declaration form for physical fitness required for driving license applicants. It collects personal information and poses a series of health-related questions to assess the applicant's fitness to drive. The form also includes instructions for applicants who may need to provide additional details based on their responses.

Uploaded by

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

APPLICATION-CUM-DECLARATION AS TO PHYSICAL FITNESS

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.

Note: This form is for reference only and not to be used for making application. For Driving
License application form please visit your near License Authority

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