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    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

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    Pradyumna Dangewar
    1. This is a medical certificate for a driver's license applicant named Utkarsh Subhas Dangewar. 2. The doctor conducted an examination and found no defects in vision, hearing, or physical ability that would interfere with driving duties. 3. The doctor certified that Utkarsh is medically fit to hold a driving license based on the examination.

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    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

    Uploaded by

    Pradyumna Dangewar
    498 views1 page
    1. This is a medical certificate for a driver's license applicant named Utkarsh Subhas Dangewar. 2. The doctor conducted an examination and found no defects in vision, hearing, or physical ability that would interfere with driving duties. 3. The doctor certified that Utkarsh is medically fit to hold a driving license based on the examination.

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    1. This is a medical certificate for a driver's license applicant named Utkarsh Subhas Dangewar. 2. The doctor conducted an examination and found no defects in vision, hearing, or physical ability that would interfere with driving duties. 3. The doctor certified that Utkarsh is medically fit to hold a driving license based on the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    498 views1 page

    Form 1-A (See Rules 5 (1), (3), 7,10 (A), 14 (D), and 18 (D) ) : Certificate of Medical Fitness

    Uploaded by

    Pradyumna Dangewar
    1. This is a medical certificate for a driver's license applicant named Utkarsh Subhas Dangewar. 2. The doctor conducted an examination and found no defects in vision, hearing, or physical ability that would interfere with driving duties. 3. The doctor certified that Utkarsh is medically fit to hold a driving license based on the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    FORM 1-A Appl No:3005998420 Dt:19-10-2020

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

    MEDICAL CERTIFICATE
    [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 referred to under sub section (3) of section 8]

    1.Name of the applicant : UTKARSH SUBHAS DANGEWAR

    2. Identification marks : 1.MOLE ON CHEST


    2.MOLE ON NECK
    3.
    (a) Does the applicant, to the best of your judgment, suffer from any defect Yes / No
    of vision? If so, has it been corrected by suitable spectacles ?

    (b) In your opinion, is he able to distinguish with his eye sight at a distance of 25 Yes / No
    metres in good day light a motor car number plate ?

    (c) In your opinion, does the applicant suffer from a degree of deafness Yes / No
    which would prevent his hearing the ordinary sound signals ?
    Yes / No
    (d) In your opinion, does the applicant suffer from night blindness ?

    (e) Has the applicant any defect or deformity or loss of member which would Yes / No
    interfere with the efficient performance of his duties as a driver? If so, give
    your reasons in details.

    (f) Optional
    (a) Blood group of the applicant (if 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 his driving licence).
    Declaration made by the applicant in Form 1 as to his physical fitness is attached

    Certificate of Medical Fitness


    I certify that:-
    (i) that I have personally examined the applicant Shri/Smt/Kum: UTKARSH SUBHAS DANGEWAR
    (ii) that while examining the applicant I have directed special attention to her/his distant vision;
    (iii) while examining the applicant, I have directed special attention to his/her hearing ability, the conditon of the arms,
    legs, hands and joints of both extremities of the applicant;
    (iv) I have personally examined the applicant for reaction time, side vision and glare recovery, (applicable in case of
    persons applying for a licence to drive goods carriage carrying goods of dangerour or hazardous nature to
    human life); and
    (v) Applicant’s colour vision has been tested using standard ishihara chart and the applicant has not been found
    suffering from severe or total colour blindness”.
    And, therefore, I certify that, to the best of my judgment, he is medically fit/not fit to hold a driving licence.
    The applicant is not medically fit to hold a licence for the following reasons : -
    Signature :
    1. Name and designation of the of Medical Officer / Practitioner

    (Seal)
    2. Registration Number of Medical Officer

    Signature or thumb impression of the candidate

    ( UTKARSH SUBHAS DANGEWAR )


    Date :
    Note : -1. 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.
    2. Dumb persons without deafness may be granted a valid certificate of driving licence for
    non-transport vehicle. __________

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