FORM 1-A [See rules 5(1),(3),7,10(a).14(d), and 18(d)} MEDICAL CERTIFICATE 1d for the purpose by the State Government or person or sub section (3) of section 8] 1 ANN} 010 53200822 ‘Appl No 9653200822 01:12-09-2022 [To be filed in by @ registered medical practitioner appoint authorised in this behalf by the State Government referred to und 1.Name of the applicant NISHANTA KUMAR BASISTHA 2 ldenilicatoa marks 1,BIRTH MARK ON RIGHT ARM. 2.MOLE ON RIGHT CHEEK (a) Does the applicant, to the best of your judgmen|, sulfer trom any defect of vision? If so, has it been carrecied by suitable spectacles ? 4 (b) In your opinion, is ne able to distinguish with his eye sight al a dstance of 25 metres in good day light a motor car number plate ? of deatness (c) In your opinion, does the applicant suffer from a degre} which would prevent his hearing the ordinary sound signals ? (2) In your opinion, does the applicant suffer from night blindness ? (2) 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 ¢0, give your reasors in details. {) Optonal {2) Blood group of the applicant (if the applicant so desires that the ae Information may Se noted in his driving licence). 'b) RH factor of the applicant (if he applicant so desires that the information may 8e noted in his driving licence). Declaration mage by the applicant in Form 1 as to his physical filness is altached . Certificate of Medical Fitness cerity that (\) that | have personally examined the applicant Shri/SmtKum: NISHANTA KUMAR BASISTHA \i) that while examining the applicant I have directed special attention to herhnis distant vsion; (i) while examining the appleant. | hava directed special attention to his/ner hearing abilty, the conditon of the arms lags, hands and joints of bath extremities of the applicant, (iv) Inave personally examined ne applicant for reaction time, side vision ana glare recovery, (applicable in case of persons applying fora licence to drive goods cariage camying goods of dangerour or hazardous nature to human life). and (v) Applcant’s colour vision habitiziytgsted using standard ishihara chart ard the applicant has not teen found suffering from severe @Pie\al colour blindness. And tneetore leery fia) (Hebe of ny jucgment, ne is med\callyftnatp hed acrving Keene The applicants not meal t16 ld a cence forthe follow asap. a f j ig hue 1) nave an ee ti ish Bins cer | Practitioner Sue \ 2. Registration Number of w BD Signature or thumb impression of the candidate - bate QF [22 ( NISHANTA KUMAR BASISTHA ) Note : -1. The medical Officer shall affix hrs signature over the photograph affixed in such a manner that part ols signature 6 upon the photograph and pat onthe coral 2. Dumb persons without deatness may be granted a valid ceriificate of driving licence for non-transport vehicle.