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The document is an application for a physical fitness declaration for Sandeep Sunil Kumar, including personal details such as name, address, date of birth, and identification marks. It contains a series of health-related questions that the applicant must answer to assess fitness for driving. The applicant must sign the declaration affirming the truthfulness of the provided information and may need to submit additional medical documentation if certain health issues are indicated.

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Sandeep Kiran
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5 views

Form1

The document is an application for a physical fitness declaration for Sandeep Sunil Kumar, including personal details such as name, address, date of birth, and identification marks. It contains a series of health-related questions that the applicant must answer to assess fitness for driving. The applicant must sign the declaration affirming the truthfulness of the provided information and may need to submit additional medical documentation if certain health issues are indicated.

Uploaded by

Sandeep Kiran
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:3030232024 Dt:16-08- CMV FORM 1

2024 [See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : SANDEEP SUNIL KUMAR

2. Father's Name : SUNIL KUMAR

3.Permanent address : 27 H
AMMAN COIL BACK SIDE PALLIVILAI NAGERCOIL Vetturn
AGASTHEESWARAM KANNIYAKUMARI TAMIL
629003

4.Temporary address : 27 H
AMMAN COIL BACK SIDE PALLIVILAI NAGERCOIL Vetturn
Official address (if any)
AGASTHEESWARAM KANNIYAKUMARI TAMIL
629003

5. (a) Date of birth : 30-06-2004


(b) Age on date of application : 20 years
6. Identification marks : 1.MOLE ON LEFT ARM
2.MOLE ON RIGHT ARM

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


( SANDEEP SUNIL KUMAR )

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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