FORM 1A
[Refer Rules 5(1), (3), 7, 10(a), 14(d) and 18(d)] FORM 1A
Space for
Passport
size
Photograph
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
...............................
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 judgment,
suffer from any defect of vision? If so, has it been
corrected by suitable spectacles?
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 member which would interfere with the efficient
performance of his duties as a driver? If so, give your
reasons in details.
Yes/No
(g) 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)