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    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

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    Chandan Mohanty
    1. This is a medical certificate for a driver's license application. It contains information about the applicant like name, address, identification marks, and date of birth. 2. The examining doctor has checked the applicant's vision, hearing, limb function, and reaction time to determine medical fitness to drive. 3. The doctor certifies that after examination, the applicant Behera Kamalakanta is medically fit to hold a driving license.

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    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

    Uploaded by

    Chandan Mohanty
    19 views1 page
    1. This is a medical certificate for a driver's license application. It contains information about the applicant like name, address, identification marks, and date of birth. 2. The examining doctor has checked the applicant's vision, hearing, limb function, and reaction time to determine medical fitness to drive. 3. The doctor certifies that after examination, the applicant Behera Kamalakanta is medically fit to hold a driving license.

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    1. This is a medical certificate for a driver's license application. It contains information about the applicant like name, address, identification marks, and date of birth. 2. The examining doctor has checked the applicant's vision, hearing, limb function, and reaction time to determine medical fitness to drive. 3. The doctor certifies that after examination, the applicant Behera Kamalakanta is medically fit to hold a driving license.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    19 views1 page

    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

    Uploaded by

    Chandan Mohanty
    1. This is a medical certificate for a driver's license application. It contains information about the applicant like name, address, identification marks, and date of birth. 2. The examining doctor has checked the applicant's vision, hearing, limb function, and reaction time to determine medical fitness to drive. 3. The doctor certifies that after examination, the applicant Behera Kamalakanta is medically fit to hold a driving license.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    FORM 1-A

    [See rules 5(1),(3),7,10(a),14(d), and 18(d)] Application Date:

    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 : BEHERA KAMALAKANTA
    1A-Son/Wife/Daughter of : BEHERA MONARANJAN
    1B-Permanent address : , Baleswwar Industrial Estate (OG, Baleshwar (M),Balasore,OD,
    756019
    1C-Date of birth : 07-05-1970
    2. Identification marks : 1.A BLACK MOLE ON MY FACE

    3.
    (a) Does the applicant, to the best of your judgment, suffer from any defect
    of vision? If so, has it been corrected by suitable spectacles ? Yes/No

    (b) In your opinion, is he able to distinguish with his eye sight at a distance
    Yes/No
    of 25 meters in good day light a motor car number plate ?

    (c) In your opinion, does the applicant suffer from a degree of deafness
    which would prevent his hearing the ordinary sound signals ?
    Yes/No
    (d) In your opinion, does the applicant suffer from night blindness ?
    Yes/No
    (e) 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.
    (f) Optional
    (a) Blood group of the applicant (if the applicant so desires that the
    O+
    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). ..........................
    Declaration made by the applicant in Form 1 as to his physical fitness is attached
    Certificate of Medical Fitness
    I certify that:-
    (i) that I have personally examined the applicant Shri/Smt/Kum: BEHERA KAMALAKANTA
    (ii) that while examining the applicant I have directed special attention to her/his distant vision;
    (iii) while examining the applicant, I have directed special attention to his/her hearing ability, the conditon 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, (applicable in case of
    persons applying for a licence to drive goods carriage carrying goods of dangerour or hazardous nature to
    human life); and
    (v) Applicant’s colour vision has been tested using standard ishihara chart and the applicant has not been found
    suffering from severe or total colour blindness”.
    And, therefore, I certify that, to the best of my judgment, he is medically Fit/UnFitto hold a driving licence.
    The applicant is Fit/UnFit to hold a licence for the following reasons : -
    Signature : ,
    1. Name and designation of the of Medical Officer / Practitioner

    (Seal)
    2. Registration Number of Medical Officer:

    Signature or thumb impression of the candidate

    Date : ( BEHERA KAMALAKANTA )

    Note : -1. The medical Officer shall affix his signature over the photograph affixed in such a manner that part
    of his signature is upon the photograph and part on the certificate.
    2. Dumb persons without deafness may be granted a valid certificate of driving licence for
    non-transport vehicle. __________

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