FORM 1A

[Refer Rules 5(1), (3). 7. 10(a). 14(d) and 18(d)I

MEDICAL CERTIFICATE
(To be filled in by aregistered medical
the State Governnment or person practitioner appointed f
referred to under sub-section (3) ofauthorised
section 8)
in this behalf by thes
Ex- M.
Govt. Dispensary
1. Name of the applicant Regd. No.-16106
Delhi VMedical..GQUncil
1A Son/wife/ daughter of
1B. Permanent Address
1C. Date of Birth]
2 Identification marks
(1).
(2)....
3. (a) Does the applicant, to the best of your
suffer from any defect of vision? If so, has judgment, Yes/No
it been
corrected by suitable spectacles?
(c) In your opinion, is he able to
distinguish with his Yes/No
eyesight at a distance of 25 metres in good day light a
motor car number plate?
(d) In your opinion, does the applicant suffer from a
degree of deafness which would prevent his hearing Yes/No
the ordinary sound signals?
(e) In your opinion, does the applicant suffer from Yes/No
night blindness?
() Has the applicant any defect or deformity or loss Yes/No
of member which would interfere with the efficient
performance of his duties as a driver? If so, give your
reasons in details.
(g) Optional
(a) Blood group of the applicant (qf the applicant so
desires that the 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 bis
driving licence)
 certificate.
licence such
Notes fit
..3t Date to
2. a The holdAnd,
1:The Declaration
I
Dumb
for manner
(V) (IV) (11) (11)certify
apPplicant (1)
non-transport therefore,a
blindness.
driving
Applicant's life).
aPplicantthe carriage
goods glare hearing
extremities ability
this/her
hdistant
1 whileevision; that
have T
have that
persons medical
that
recovery. while made
is examining
personally personally :
part licence
without
notcertify I by
officer colour exanmining
of
vehicle. medically the
of hasnotcarrying the
to been (applicable applicant
his that, Certificate
shall drive applicant; theexamined
deafness vision examined conditiontheof
signature applicant.
to the
affix fit a goods
vehicle the has in
Signature
thumb or to of
his
inthe
and
apnlicant the Form
may hold suffering
best foundbeen case Medical
is of
signature Ex- applicant applicant
I
beupon other dangerous of bave Ias
2 Dr. 1. a of tested
Regisration licence mny persons hands to
granted Medica! Name arms.
legs,
S. judgement, than directed have LFitness his
the using
(PhysiciajIcer/practitioner
over MD for for
Shri/Smt./Kum. physical
photograph Dispensary P.
and an or
F severe
from applying
reaction directed
valid
a impression Officer the
adapted hazardous
standard special
nmbetofi'edical the
designmen following fitness
photograph SignaturF he
certificate Delhi fortime,attentionspecial
vehicle. is ishihara and
and medically is
of colour nature
totalor licence side a attached.|
the (Seal) reasons of joints
part the attention
candidate
ofaffixed chart vision
to to
driving on fit/not human to his/her of
officer medical drive
the and and both
in to