FORMS                                          No.-NLG/Y/91  Sl. No.

(See rule - 5,7,10 (a) and 14(d)

Medical Certificate in respect of an applicant for obtaining a Learners License/driving license or renewal of driving license.

Part - 1

                                                                               Photo 

(TO BE FILLED BY THE PPLICANT)

1.  Name of the applicant       

(In block letter)            

2.  Son /Wife/daughter of        

3.  Permament address           

                     Village             

                    Post                 

                    P.S.                 

                District                 

                State                   

4.  Present Lical address     

5.  Official address (if any)   

6.  Date of birth (age)          

7.  Identification Marks       

DECELERATION AS TO PHYSICAL FITNESS TO BE BY THE APPLICANT

  1. Do you suffering from epilepsy, or from sudden attack of loss of consiousness or gidness form any cause.                                                                                                                                              Yes/No

  2. Are you able to distinguish with each eye at a distance of 25 metres in good day light (with glassess if worn)                                                                                                                                                Yes/No

  3. Have you lost either hand or foot or are you suffering from any defect in movement control or mucular power of of either arm or leg ?                                                                                                                            Yes/No

  4. Can you readily distinguish the pigmentary colours red and green ?                                                        Yes/No

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

  6. Are you so dear as to be unable to hear [and if the applicant is for driving a light motor vehicle with or without bearin aid] the orginal sound signal ?                                                                                                    Yes/No

  7.   Do you suffer from any other disease or disability likely to cause you driving of a motor vehicle to be a source of danger to the public if so, give details.                                                                                               Yes/No 

                I have decalre that the best of my knowledge and belief the particulars given above and the decelaration made here in true.

Signature of the applicant

NOTE : An applicant who's answer has to any of the question (a) (c)(e) [i] [g] on No to either of the question (b)  &  (d)  should amplify his answer.

With full particulars and may be required to give further information relating there to 

PART - II

    ( To be filled in by registered medical practioner appointment for purpose the state Government or person authorized in this behalf by the State Government reffered to under sub-section (3) of section (8).

1.  Name of the applicant :     

2.  Son/Wife/Daughter of :     

3.  Permament Address :       

4.  Present local address :      

5.  Date of birth (Age) :          

6.  Two Identificatio marks :   

7.  a)  If the applicant to the best of your judgement subject to epllersy, vertigo, or any mental alltment likely to affect this driving efficency ?                                                                                                                                   Yes/No