CPL Driver form 5

                                                                                     5

Part -III

           

(To be filled by registered medical practitioner appointed by the state Government or person authorized in his behalf by the state Government. referred to under sub-section 3 of section 8)

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 Mark 2(two)                         :  1. ………………………………..

                                                                                    2. ………………………………..

7.         a)   If the applicant to best of your judgment subject to epilepsy, vertigo,         Yes/No

            or any mental ailment likely to affect this driving efficiency.

b)  Dose the applicant suffer from any heart/lung disorder which might            Yes/No

interfere with the performance of his driving.

c)   Is there any defect of vision? If so has it been correct by suitable                Yes/No

spectacle?                

d)  Can the applicant readily distinguish the pigmentary colors red & green?   Yes/No

g)   Has the applicant any deformity of loss number which would interfere       Yes/No

 with the efficient performance of his duties?

h)   Does the suffer from attach of loss consciousness from any case?            Yes/No

i)   Is he suffering any defect in movement control or muscular power               Yes/No

 of either arm of limb?

j)   What is the  height of the applicant? Do you consider that this height will   Yes/No

 be disadvantageous or him to have a clear vision of the road while driving?

k)  Is he a mentally ill person?                                                                                 Yes/No

l)   Does he suffer from any other disease or disability like cause his               Yes/No

driving a motor vehicle a source to the public ?

m)  Is he in your opinion generally fit as regard?                                                  Yes/No

n)   Blood group of the applicant?                                                                         Yes/No

o)   RH Factor of the applicant?                                                                            Yes/No

I have examined the applicant, I am of the opinion that he is fit / not fit to hold driving license for the above reasons.

Dated :                                                                                               Name & Designation

Place  :                                                                                            The Medical Officer.

                                                                                                                        (with seal)