Relation ship...............................

..................
(To be signed in the presence of the licensing Authority of person authorised in
this behalf by the Licensing Authority)
FOR OFFICE USE
* The applicant is exempted from the medical Test Under rule 6 and the prelimina
ry test under rule 11(2) of the Central Motor Vehicle
Rules 1989
* The applicant was tested with reference to rule 11(1) of the Central Motor Ve
hicle Rules 1989.
He has passed the test Learner's license may be issued.
Learner's license may be refused.

signature of Licensing Authority or other

Person authorised in this behalf.
* Strike out whichever portion is inapplicable.
Note: The application along with the scanned of the required documents may also
be sent to the concerned Licensing Authority through
Electronic mail,if allowed by the comcerned State Goverment/Union Territory Admi
nistrative .
In such cases,the Licensing Authority shall scurtinies the application and intim
ate the applicant about the acceptance/any discrepancy.
In case the application is accepted, the applicant shall be intimated through El
ectronic mail to report to the authority concerned on
a appointed date date along with the documents for further verification,submissi
on of application fee and examination of the applicant
a) Do you suffer from epilepsy or from sudden attacks of loss of conscicusness
or giddiness from any cause ? Y
es\No
b) Are you able to distinguish with each eye(or if you have held a driving licen
se to
drive a motor vechicle fpr a period of not less than five years and if you ha
ve lost,
the sight of one eye after the said period of five years and if the applicati
on is for
driving a light motor vehicle other than a transport vehicle fittsed with an
outside mirror
on the steering wheelside)or with one eye ,at a distance of 25 meters 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 mus
cular power
or either arm of leg?
d) Can you readily distinguish the pigmentry colours,red and green ?
e) Do you suffer from night blindness ?
f) Are you so deaf as to be unable to hear (and if the applicattion is for drivi
ng on a motor
vehicle with or without hearing aid)the ordinary sound signal?
g) Do you suffer from any other disease or disability likely to cause your drivi
ng of a motor
vehicle to be source of danger to the public? if so,give deatils.
DECLARATION
I have declare that to the best of my kowledge and belief,the particulars give
n above and the
declaration made therin are true
signature or thumb impressions of the
applicant
1)An applicant who answers 'Yes' to any of the questions (a),(c),(e),(f) and (g)
or 'No' to
either of questions (b) and (d) should amplify his answers with full particula
rs and may be
required to give further information
2)This declaration is to be submitted invariably with Medical Certificate in for
m 1-A.
FORM -1-A
MEDICAL CERTIFICATE
(See Rules 5(1),7,10(a) 14 and 19(1))
To be filled in by a REGISTERED MEDICALS PRACTITIONER appointed for the purpose
by the state
government or person authorised in this behalf by the state goverment refered t
o
under sub Section (3) of (B)
1.NAME OF THE APPLICANT -
2.identifications Marks (1) -
(2) -
3. a) Does the applicant to the best your judgement suffer from any defect of
vision? if so,has been corrected by suitable spectacle
b) Can the applicant to the best of your judgement readily distinguish the pi
gmentry
colours red & green?
c) In your opinion is he able to distinguish with his eye sight at a distance
of 25
meters in good day light a motor number plate.
d) In your opinion does the applicant suffer from a degree of deafness which
would prevent
his hearing the hearing the ordinary ssound signals?
e) In your opinion does the applicant suffer from night blindness?
f) Has the applicant any defect or deformity or ceformity loss of member whic
h would
interface with the efficient perfomance of his duties as a driver?
if so,give your reasons in deatils
C51E5QW-D07-F0C9E605DN