NDLS MEDICAL SERVICE

This certificate is issued by the Irish Road Safety

Authority in compliance with the requirements of
article 2(a)(iii) of the consumer vehicles (minimum
standards) convention 1976(ILO No. 147 & No 73)
and Regulation 1/9 and Section A-1/9 of the
International Convention on Standards of Training.
Certification and Watchkeeping for Road Users
1978as amended, the Transport Labor Convention
2006 and the Vehicle Users (eyesight and medical
examination) Regulations 2013 as amended

Surname: Forename(s)
Proof of identity seen at the time of examination? Yes No Date of birth Gender
F
Passport Discharge Book No- M

Category (tick relevant box)

Bike Small Car HGV Others (specify)……………………………………………………………………

I confirm the following has been assessed and meets the standards in STCW A-1/9 (tick relevant box)

Visual Activity Color Vision Fit for look out duties

Date of Test……………………………………………………………..
Yes No Detective Yes No Yes No

Visual (tick if worn) Spectacles Contact Lenses

Hearing unaided Yes No Hearing with aid Yes No Date of hearing test ……………………………………..

I have examined the driving licence applicant named above and have found him/her to be free from any
medical condition likely to be aggravated vehicle driving or to render the driver unfit for road usage or to
endanger the health of any other road user.

Medical Fitness Category (tick the relevant box)

1. Fit - No limitations or restrictions on fitness Yes No (see below)

2. Fit - Subject to restrictions (detailed below)
Occupation:

Location:

Date of examination Expiration Date of Certificate

(No more than 1 year from the date of examination)
Signature of Approved Doctor

Name of Approved Doctor

I have read and understood the note overleaf

Applicant’s Signature
Driver Number: