CPL Driver 4

                                                                                                                        4

FROMS

SEE RULE 2 (B) , RULE 5,7, 10(a) & 14 (C)

Medical certificate on respect of applicant for obtaining a learners license/driving license of renewal of driving license.

Part- I

Photo

 

1.         Name in full (In block capital letters)       : 

2.         Son/Wife/Daughter of :

3.         Permanent Address                                 :  

4.         Present Address        :

5.         Date of Birth (age) with proof                  :

6.         Identification Marks                                  :      1. …………

                                                                                   

   2. …………

                                                                       

Part II

DECLARATION AS TO PHYSICAL FITNESS TO BE GIVEN BY THE APPLICANT

1.    Do you suffer from epilepsy, or from sudden of loss consciousness or                   Yes/No.

giddiness from any cause?.

2.   Are you able to distinguish with easy eye at a distance 25 mtr. In good day          Yes/No

 light with glasses, (if worm)?

3.   Are you suffering by any hand/foot or defect in movement control                           Yes/No

or muscular power of either arms or leg?

4.   Can you readily distinguish the basic colors red & green?                                      Yes/No.

5.   Do you suffer from night blindness?                                                                                       Yes/No

6.   Are you here ordinary sound signal.?                                                                         Yes/No

7.  Do you suffer from any other disease or disability which danger to the                  Yes/No

public while you drive a vehicle. if so, give details?

                                                                                               

(Signature of the applicant)

Place :                                                                                             Name,

Date  :                                                                                             Code No

Note:- An applicant who answer ‘YES’ to any of the questions 1,3,5,7, or ‘NO’ to the questions 2 ,4 & 6. Should amplify his answer with full particular may be required to give further information relating thereto.