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) __________________
(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.