Medical Certificate PDF Bala Ram

FORM 1-A [See rules 5(1),(3),7,10(a),14(d), and 18(d)] Application Date: MEDICAL CERTIFICATE [To be filled in by a registered medical practitioner appointed for the purpose by the State Government o...

FORM 1-A [See rules 5(1),(3),7,10(a),14(d), and 18(d)] Application Date: 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 : BALA RAM 1A-Son/Wife/Daughter of : PAPPA RAM 1B-Permanent address : V/P MEGHWALO KI DHANI RAMDERIYA P SAWAU, MOOL RAJ TEH GIDA DIST BARMER, BAYTOO,BARMER, 344037 1C-Date of birth : 11-08-1992 2. Identification marks : 1................................. 3. 2................................. (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 (b) In your opinion, is he able to distinguish with his eye sight at a distance Yes/No of 25 meters in good day light a motor car number plate ? (c) In your opinion, does the applicant suffer from a degree of deafness which would prevent his hearing the ordinary sound signals ? Yes/No (d) In your opinion, does the applicant suffer from night blindness ? Yes/No (e) 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 Yes/No your reasons in details. (f) Optional (a) Blood group of the applicant (if the applicant so desires that the Unknown 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: BALA RAM (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 to hold a driving licence. The applicant is 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 Date : ( BALA RAM ) 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. __________