KEMBAR78
License Form | PDF | Transport | Vehicles
Scribd
Upload
90 views1 page

License Form

1) Nikhil Verma, son of Manoj Verma, applied for a physical fitness declaration for a driving license. 2) He lists his permanent and temporary addresses in Meerut, Uttar Pradesh and provides his date of birth and age. 3) He declares that he does not suffer from any conditions like epilepsy, loss of consciousness, or defects in limbs or senses that would impair his ability to drive safely.

Uploaded by

Nikhil Verma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
90 views1 page

License Form

1) Nikhil Verma, son of Manoj Verma, applied for a physical fitness declaration for a driving license. 2) He lists his permanent and temporary addresses in Meerut, Uttar Pradesh and provides his date of birth and age. 3) He declares that he does not suffer from any conditions like epilepsy, loss of consciousness, or defects in limbs or senses that would impair his ability to drive safely.

Uploaded by

Nikhil Verma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

CMV FORM 1 Appl No:1654860320 Dt:08-07-2020

[See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : NIKHIL VERMA

2. Father's Name : MANOJ VERMA

3.Permanent address : 57
SURYA PURAM DELHI ROAD
MEERUT,U.P.
250004

4.Temporary address : 57
Official address (if any) SURYA PURAM DELHI ROAD
MEERUT,U.P.
250004

5. (a) Date of birth : 24-10-1998


(b) Age on date of application : 21 years
6. Identification marks :

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of


loss of consciousness or giddiness from any cause ? Yes / No

(b) Are you able to distinguish with each eye ( or if you have
held a driving licence 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 Yes / No
vehicle fitted with an outside mirror on the steering wheel
side) or with one eye, at a distance of 25 metres 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 Yes / No
from any defect in movement, control or muscular power of either
arm or leg ?

(d) Can you readily distinguish the pigmentary colours, red Yes / No
and green ?

(e) Do you suffer from night blindness ? Yes / No

(f) Are you so deaf as to be unable to hear ( and if the


application is for driving a light motor vehicle, with or without Yes / No
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
Yes / No
to the public, if so, give details?

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


( NIKHIL VERMA )

Note : - (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 1-A.

You might also like