Application for Driving License Medical Certificate

CMV FORM 1

Application –cum-declaration as to the physical fitness

1. Name of the applicant:

2. Son/ wife/ daughter of:

3. Permanent address:

4. Temporary address / Official address (if any):

5. (a) Date of birth:

    (b) Age on date of application:

6. Identification marks (1):

        (2):

Declaration :

(a) Do you suffer from eplipsy 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 with one eye, as applicable) a motor car number plate at 25 metres in good daylight? Yes No

(c) Have you lost either hand or foot or are you suffering from any defect in movement, control 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 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 given above and the declaration made therein are true.

Note :

(1) An 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 with Medical Certificate in Form 1-A.

CMV Form 1-A

Medical Certificate

[ To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person authorised in this behalf by the State Government referred to under sub-section (3) of Section 8]

1. Name of the applicant:

2. Identification marks (1):

    (2):

3. (a) Does the applicant suffer from any defect of vision? If so, has it been corrected by suitable spectacle? Yes No

    (b) Can the applicant readily distinguish the pigmentary colours, red and green? Yes No

    (c) Is he able to distinguish with his eyesight at a distance of 25 metres in good daylight a motor car number plate? Yes No

    (d) Does the applicant suffer from a degree of deafness which would prevent hearing the ordinary sound signals? Yes No

    (e) Does the applicant suffer from night blindness? Yes No

    (f) Has the applicant any defect or deformity or loss of member which would interfere with the efficient performance of his duties as a driver? If so, give reasons in details: Yes No

    (g) Optional blood group of the applicant:

    RH factor of the applicant:

Declaration made by the applicant in Form 1 as to his physical fitness is attached.

Certificate of Medical Fitness

I certify that:

(i) I have personally examined the applicant Shri/ Smt./Kum

(ii) That while examining the applicant I have directed special attention to his / her distant vision.

(iii) While examining the applicant, I have directed special attention to his / her hearing ability, the conditions of the arms, legs, hands and joints of both extremities of the applicant.

(iv) I have personally examined the applicant for reaction time, side vision and glare recovery.

and, therefore, I certify that, to the best of my judgment, he is medically fit / not fit to hold a driving licence.

The applicant is not medically fit to hold a licence for the following reasons: