FORM 1A
Medical Certificate

[See Rules 5(1),(3),7,10(a),14(d) and 18(d)]

[To be filled in by a registered medical practitioner appointed for the purpose by the state Government or
person authorised in this behalf by the State Government reffered to under Sub-Section (3) of section 8]
  1. Name of the Applicant:


  2. Identification Marks: 1.
    2.


  3. (a) Does the applicant to the best of your judgement suffer from any defect of vision
    If,so,has it been corrected by suitable spectacle?
    Yes No
    (b) Can the applicant to the best of your judgement readily distinguish the pigmentary
    colours, red and green?
    Yes No
    (c) In your opinion, is he able to distinguish with his eyesight at a distance of 25
    metres in good day light a motor car number plate.
    Yes No
    (d) In your opinion does the applicant suffer from a degree of deafness which would
    prevent his hearing the ordinary sound signals?
    Yes No
    (e) In your opinion does the applicant suffer from night blindness? Yes No
    (f) Has the applicant any defect or deformity or loss of memory which would interfere
    with the efficient performance of his duties as a driver? If so, give your reasons in
    detail.
    Yes No
(g) Optional
(a) Blood group of the applicant
(If the applicant so desires that the information be noted in his Driving Licence)
(b) Rh factor of the applicant
(If the applicant so desires that the information be noted in his Driving Licence)

Declaration made by the applicant in Form-I as to his physical fitness is attached

Certificate of Medical Fitness

I Certify that:
  1. I have personally examined the applicant Shri/Smt/Kum .
  2. That while examining the applicant I have directed special attention to his/her distant vision;
  3. While examining the applicant, I 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
  4. I have personally examined the applicant for reaction time, side vision and glare recoverery,
    (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, to the best of my Judgement, he is medically fit/not fit to hold a driving Licence.

The applicant is not medically fit to hold a Licence for the foloowing reasons:
 
Signature:
  1. Name,designation and
    Reg. No. of
    Medical Officer/Practitioner
    (seal)

    Signature / thumb impression
    of the candidate
Note:- The Medical Officer shall affix his signature over the photograph affixed in such a manner that part of his signature is upon the photograph and part on the certificate.