FORM 1-4, [See Rules 5(1), 3s (7) 10(@), 14(a) CAL CERTIFICATE 8! [To be filled in by a registered medical inted fe rma din b practitioner appointed for the purpose by_the State Govern authorised in this behalf by the State Government referred to under sub-section (3) of Section 8.) URBAN T nen SING Hieonel All. MOLEC oe L EE Tosser IG 1, Name of the applicant 2. Identification marks a Declaration: {@) Does the applicant, tothe best of your judgment, suffer from any defect of vision? If'so, has” Yesno it been corrected by suitable Spectacles? (b) Can the applicant, to the best of your judgment readily distinguish the pigmentary colours, Yesivo red and green? inguish with his eyesight ata distance of 25 metres in goody ‘Yesino (©) In your opinion, is he able to day light a motor car mumber plate? (@) In your opinion, does the applicant suffer from a degree of deafness which would prevent his hearing the ordinary sound signals? Yeuno (e) In your opinion, does the applicant suffer from night blindness? Yeone~ (Has the applicant any defect or deformity or loss of member which would interfere with the a iver? If so, give your reasons in detail. YestNo efficient performance of his duties as dri (g) Optional {the applicant so desires that the information may be noted CQ) (a) Blood Group of the applicant (i in his driving licence), : int (if the applicant so desires thatthe information may benoted in QJ4-+V€ (b) RH factor of the applica his driving licence). Declaration made by the applicant in Formm-1 as to his physical fitness ts attached.certificate of Medical Fitness {certify that= - {have personally examined the appar SHVSOUKUM.. UR T IT... SUNG, MALL Gi) that white examining the applicant Lave diectedsPEal attention to Mer distant vision; (ii) while examining the appli directed special attention to High it wplicant, I have direct 0 liner hearing ability, the condition ofthe arms, legs, hands and joints of both extremities of the applicant; ang ration of th (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 dangerous or hazardous nature to human life). =< ‘And, therefore, I certify that, tothe best of my judgment, he is melcally vt fit to hold a driving licence. ‘The applicant is not medically fit to hold a licence forthe following reasox wo Herat | 1. Nane and signatono thee Steehaciieeeenect OO 1. HERTS steer “Kans 2. Registration Number of Medical Offi=: (MCHA G Dono 26,2] sigue ce thunb inprssion ofr ante Date: } Note 1. - The medical officer shall affix his signature over the photograph af signature is upon the photograph and part on the certificate. 2. Dumb persons without deafness may be granted a valid ceri ‘fixed in such a manner that part of his ficate of driving licence for non-transport vehicle,