FORM 1A (Refer Rules S(1), (3), 7. 10(a). 14¢d) and 18¢¢)) MEDICAL CERTIFICATE (Ta be filled in by a registered medical practitioner appointed for the purpose by: the State Covernment or person authorised in this behalf by the State Government referred to under sub-section (3) of section 8) 1 1A 1B, 1c 2 3 Name of the applicant Guucem Ragool baw son/wife/daugherat ABUL REMMan Dre. PermanentAddress SaavaT A a4 aqe-s Serbs ne, KH ADE. DateofBirhl IY fod] 144g Identification marks (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? (2) In your opinion. is he able to distinguish with his eyesightat a distance of 25 metres in good day ight a ‘motor ear number plate? (a). In your opinion. dees the applicant suffer fram a degree of deafness which would prevent his hearing the ordinary sound signals? (©) In your opinion, does the applicant suffer from night biindness? (0 Has the applicant any defect or deformity or loss of member which would interfere with the efficient performance of his duties as a driver? Iso. glve your Feasons in details (@) Optional (@) Blood group of the applicant (iftheapplicant so desires that the information may be noted in his driving licence) (b) RH factor of the applicant Uf the applicant so ‘desires that the information may be nated in his driving licenced ).Sfake em Mere « (2. Yes/No Yes Yes/Nd-~ Yes/Nb oO TENE[Declaration mack by the applicant in Form sto his physical ness is attached] Certificate of Medical Fitness Teertify that — ww (0) Thave personally examined the applicant Shri/Smt./Kum, Gates Meet oot Dare (G) that while examining the applicant I have directed special attention to his/her distant vision; (Gi) while examining the applicant, [have directed special attention to his/her hearing ability the condition of the arms, legs, hands and joints of both extremities of the applicant: and. iv} Thave personally examined the applicant forreaetion time, side vision and glare recovery, (applicable in case of persons applying fora licence to drive goods carriage carrying goods of dangerous or hazardous nature to human li. (1 Applicant's colour vision has been tested using standard ishthara chart and the applicant has not been found suffering. from severe or total colour blindness. Ke And, therefore, I certify that, to the best of my judgement, he ts medically Aft {ite hold a driving licence to drive a vehicle other than an adapted vehicle. “The applicant is not medically fit to hold a licence for the following. 5 Si 1. Name and designation of ie nedkcal Dy FaLtcné favaet. p af Raofhier/ practitioner SOK Health Ser (geal CASEY. soa Serb) oe ; 2 Registration number of medical ofteer <4 2% 4 Date: LL {of ds Signature or thumb impression of the te 2 Notes 1: The medical officer shall affix his signature over the photograph Suc a manner tht part of his sgnstere fs upon the photograph and parton the certificate, 2, Dumb persons without deafness may be granted a valld certificate of driving licence for non-transport vehicle.