FORM 4

Form of Application for Licence to drive a Motor Vehicle

To

The Licensing Authority

__________________

I apply for a licence to enable me to drive vehicle of the following description :

a Motor cycle without gear

b Motor cycle with gear

c Invalid carriage

d Light motor vehicle

e Medium goods vehicle

f Medium passengers motor vehicle

g Heavy goods vehicle

h Heavy passenger motor vehicle

i Road roller

j Motor vehicle of the description

Particulars to be furnished by applicant

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

Date--------------- Signature or thumb impression of applicant.

Certificate of test of competence to drive

The applicant has passed the test prescribed under rule 15 of the Central Motor Vehicle Rules, 1989. The test was conducted on (here enter the registration mark and description of the vehicle ) on (date)----------------------

The applicant has failed in the test

(The details of the deficiency to listed out)

Dated---------------- Signature of Testing Authority Full name and designation

----------------------

---------------------

(Two specimen signature of applicant)

FORM 1

[(See Rule 5, 7, 10 (a) and 14 (b)]

Medical certificatein respect of an applicant for obtaining a learner's licence/driving licence or renewal of adriving licence

PART 1

[TO BE FILLED BY THE APPLICANT

Declaration as to physical fitness to be given by the applicant.

a] Do you suffer from epilepsy or from sudden attack of Yes/No loss of conciousness or gidelines from any cause ?

b] Are you able to distinguish with each eye at a distance of Yes/No 25 meters in good day light [with glasses, worm] ?

c] Have you lost either hand or foot or are you suffering from an Yes/No

defect in movement . Control or musculars power or either

arm or leg ?

d] Con you readily distinguish the pigmentary colours, red & green Yes/No

e] Do you suffer from night blindness. Yes/No

f] Are you so deaf as to be unable to hear and if the application Yes/No

is for driving of a light motor vehicle. with or without hearing

aid the ordinary sound signal ?

g] Do you suffer from any other disease or disability likely to cause poor

driving of a motor vehicle to be a source of danger to the public if so give detail. Yes/No

I hereby declare that the best of my knowledge and belief the particulars given above and the declaration made here in are true.

Signature of the applicant

Note :- And applicant who answer Yes to any of the questions [a c e f ] and go No' to either of the questions [b and a] should emplify his answer with full particulars and may be required to give further information relation there to.

PART 11

[To be filled by a registered medical practioner from the purpose by the State Government or person authorised in this behalf by the State Government refered to under sub-section 3 of section 8]

a] If the applicant to the best of your judgerment subject to epilepsy, vertigo or any mental ailment likely to effect his driving efficiency ? Yes/No

b] Does the applicant suffer from and health any lung disorder which might interfere with performnace of this duties as a driver ? Yes/No

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

d] Can the applicant readily distinguish the pigmentary coloureded and green ? Yes/No

e] Does the applicant suffer from a degree of deafness which would

prevent his hearing the ordinary sound signals ? Yes/No

g] Has the applicant deformity or loos of member which would interfere with the efficient pertormance of his duties as a driver ? Yes/No

h] Does he show any evidence of being a dicated to excessive use of alcohal, tobacco or drugs ? Yes/No

i] Is he bale to distinguish with each eye a distance of 25 meters in good day light motor car number plate ? Yes/No

j] Does he suffering from attacks of loss of conciousness form any cause ? Yes/No

k] Is he suffering from any defect in movement control or muscular power of either arm are limb ? Yes/No

l] What is the height of the applicant ? Do you consider that this height will be disadvantageous for him to have aclear vision of the road while driving ? Yes/No

m] Is he a mentally ill person ? Yes/No

n] Does he suffer from any other disease or disablity likety caas his delious a motor vehicle a source of danger to the public ? Yes/No

o] Is he in your opinion generally fit as regards ? Yes/No

i] Bidily health

ii] Eye Sight

iii] Mental ability

iv] Hearing ability

p] Blood group of the applicant ------------------------------------------------------

q] RH Factor of the applicant ------------------------------------------------------

I have examined the applicant. I am of the opinion that he his not fit to hold a Drivin Licence for the following reasons. ____________________________________________________ ________________________________________________________________________

Signature

Name and Designation of Medical Officer

----------------------------------------

Date-------------------------------------------------------------------------------------------

I certified that I have personally examined the applicant---------------------------------I also certify that while examinig the applicant I have directed special attention to the distant vision and hearing ability, the condition of the arms, legs, hand and joints of both extremities as the Candidate and he is medically fit to hole a driving licence.

Signature

Name and Designation of the Medical Officer __________________________________

Date __________________________________

[SEAL] Signature of the Candidate

Note :- 1. The medical officer shall affix has signature over the photograph in such a manner that part of this signature is upon the photograph and part on the certificate.

2. Particulars of the guarantee where the Medical Officer appointment is not filled with reference to sub section (3) of section 8 of the Motor Vehicle act 1989 & the number in the list where is name appears.