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  • CMV Form 1

    Enviado por

    Baljeet Singh
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    This document contains an application form for a physical fitness declaration required to obtain a driver's license. The form requests information such as name, address, date of birth, identification marks, and requires the applicant to declare whether they have any medical conditions that could impact their ability to safely drive a motor vehicle, such as epilepsy, blindness, deafness, or loss of limbs. The applicant must sign declaring that the information provided is true to the best of their knowledge. Notes at the bottom indicate that additional information may be required from applicants who answer "yes" to certain medical questions or "no" to questions about vision. A medical certificate must also be submitted with this declaration form.

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    Título original

    CMV FORM 1

    Direitos autorais

    © Attribution Non-Commercial (BY-NC)

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    This document contains an application form for a physical fitness declaration required to obtain a driver's license. The form requests information such as name, address, date of birth, identification marks, and requires the applicant to declare whether they have any medical conditions that could impact their ability to safely drive a motor vehicle, such as epilepsy, blindness, deafness, or loss of limbs. The applicant must sign declaring that the information provided is true to the best of their knowledge. Notes at the bottom indicate that additional information may be required from applicants who answer "yes" to certain medical questions or "no" to questions about vision. A medical certificate must also be submitted with this declaration form.

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    40 visualizações0 página

    CMV Form 1

    Enviado por

    Baljeet Singh
    This document contains an application form for a physical fitness declaration required to obtain a driver's license. The form requests information such as name, address, date of birth, identification marks, and requires the applicant to declare whether they have any medical conditions that could impact their ability to safely drive a motor vehicle, such as epilepsy, blindness, deafness, or loss of limbs. The applicant must sign declaring that the information provided is true to the best of their knowledge. Notes at the bottom indicate that additional information may be required from applicants who answer "yes" to certain medical questions or "no" to questions about vision. A medical certificate must also be submitted with this declaration form.

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 0

    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 on date of application
    6. Identification Marks (1) ..
    (2) ..

    Declaration,

    (a) Do you suffer from epilepsy or
    from sudden attacks of loss of
    consciousness or giddiness from
    any cause?

    (b) Are you able to distinguish with
    each eye (or if you have held a
    driving license 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 and 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 meter in good day
    light (with glasses, if worn) a
    motor car number plate?

    (c) Have you lost either hand or foot
    or are you suffering from any
    defect of muscular power of
    either arm or leg?

    (d) Can you readily distinguish the
    pigmentary colours, red and
    green?





    Yes/No















    Yes/No




    Yes/No



    Yes/No


    (e) Do you suffer from night
    blindness?

    (f) Are you so deaf so as to be
    unable to hear (and if the
    application is for driving a light
    motor, with or without hearing
    aid) the ordinary sound signal?

    (g) Do you suffer from any other
    disease or disability likely to
    cause your driving of a motor
    vehicle to be a source of danger
    to the public, if so give details?





    Yes/ No





    Yes/No





    Yes/No




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


    (Signature or thumb impression of the Applicant)

    Notes: - (1) An applicant who answers Yes to any of the questions (a), (c),
    (e), (f), and (g) or No to either of the questions (b) and (d) should amplify his answers
    with full particulars, and may be required to give further information relating thereto.

    (2) This declaration is to be submitted invariably with medical
    certificate in Form 1A.

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