Form 1a
Form 1a
Form 1a
MEDICAL CERTIFICATE
[See rules 5(1),(3),7,10(a),14(d), and 18(d)]
[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]
(b) Can the applicant, to the best of your judgment, readily distinguish the Yes / No
pigmentary colours, red and green ?
(c) In your opinion, is he able to distinguish with his eye sight at a distance of 25
Yes / No
metres in good day light a motor car number plate ?
(d) In your opinion, does the applicant suffer from a degree of deafness Yes / No
which would prevent his hearing the ordinary sound signals ?
(e) In your opinion, 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 Yes / No
your reasons in details.
(g) Optional
(a) Blood group of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).
(b) RH factor of the applicant (if the applicant so desires that the ..........................
information may be noted in his driving licence).
Signature :
1. Name and designation of the of Medical Officer / Practitioner
(Seal)
2. Registration Number of Medical Officer