FORM 1: PHYSICAL FITNESS DECLARATION FORM (APPLICATION CUM DECLARATION AS TO PHYSICAL FITNESS) RULE 5(2)

FORM 1 ABOUT PHYSICAL FITNESS DECLARATION BY THE APPLICANT (DRIVING LICENCE APPLICATION FITNESS FORM): THIS FORM MAY APPLICABLE IN BOTH - GOVERNMENT AND PRIVATE SECTORS: FORM 01 IS APPLICATION CUM DECLARATION AS TO PHYSICAL FITNESS COMES UNDER RULE 5(2): Form 1 Physical Fitness Declaration Form to be filled by the applicant either computer typed or filled by in his/ her own hand writing - what-so-ever:

--------------------------------------------BELOW IS FORM 1--------------------------------------------

FORM 1

[see rule 5(2)]

Application-cum-Declaration as to Physical Fitness

1. Name of the applicant    :  
2. Son/Wife/Daughter of     :
3. Permanent Address        :
4. Temporary Address        :
   (Official address if any)
5. (a) Date of Birth        :
   (b) Age as on date of    :
       Applicant
6. Identification Marks     : (1)
                              (2)

DECLARATION:

1. Do you suffer from epilepsy or from sudden     (Yes/No)
   attacks of loss of consciousness or giddiness
   from any cause ?
   .
2. Are you able to distinguish  with each eye     (Yes/No)
   (or  if you have held a driving licence to
   drive a  motor vehicle for a period of not
   less than five years and  if you have lost
   the sight of one eye after the said period
   of five years  & if the application is for
   driving a light motor vehicle other than a
   transport vehicle fitted with  an  outside
   mirror on the steering wheel side) or with
   one eye/at a distance of 25 meters in good
   day light(with glasses/if worn)a motor car
   number plate ?
   .
3. Have you lost  either hand or foot or are      (Yes/No)
   you suffering from any defect of muscular
   power of either arm leg ?
   .
4. Can you readily distinguish the pigmentary     (Yes/No)
   colours red and green ?
   .
5. Do you suffer from night blindness ?           (Yes/No)
   .
6. Are you so deaf as to be unable to hear        (Yes/No)
   (and if the application is from driving
   a light motor vehicle / with or without
   hearing aid) the ordinary sound signal?
   .
7. Do you suffer from  any  other disease or      (Yes/No)
   disability likely to cause your likely to
   cause your driving of a  motor vehicle to
   be a source of danger to the public ?  If
   so give details.

        I hereby declare that to the best of my knowledge and belief, the particulars given and the declarations made therein are true.

                                                        (signature or thumb impression of the applicant)

Note:

1. An applicant who answer 'Yes' to any of the questions (i),(iii),(v),(vi),and(VII) or 'No' to either of the question (ii) or (iv) should amplify his answer with full particulars and he may be required to given further information relating there to.
   .
2. This declaration is to be submitted invariably with medical certificate in Form 1-A.

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