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Driving Licence Self-Declaration Form

This document contains an application for a driving license. It includes details of the applicant such as name, date of birth, address, identification marks, and responses to questions regarding any medical conditions that could impact driving ability. The applicant declares that their responses are true to the best of their knowledge. They are required to provide further information if they answer 'Yes' to questions about conditions like epilepsy, loss of limbs or eyesight, hearing impairment, or other diseases that could endanger driving. A medical certificate must also be submitted with this declaration.

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95 views1 page

Driving Licence Self-Declaration Form

This document contains an application for a driving license. It includes details of the applicant such as name, date of birth, address, identification marks, and responses to questions regarding any medical conditions that could impact driving ability. The applicant declares that their responses are true to the best of their knowledge. They are required to provide further information if they answer 'Yes' to questions about conditions like epilepsy, loss of limbs or eyesight, hearing impairment, or other diseases that could endanger driving. A medical certificate must also be submitted with this declaration.

Uploaded by

tmenterprise cbe
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

Appl No:3743807121 Dt:27-10-2021 CMV FORM 1

[See rule 5(2)]


Application –cum-declaration as to the physical fitness

[Link] of the applicant : G MAHAMITHRAA

2. Father's Name : SBV GUPTHA

[Link] address : 234 9TH STREET GANDHIPURAM


Coimbatore (M Corp.), Coimbatore (M Corp.)
Coimbatore South,Coimbatore,TN
641012

[Link] address : 234 9TH STREET GANDHIPURAM


Coimbatore (M Corp.), Coimbatore (M Corp.)
Official address (if any)
Coimbatore South,Coimbatore,TN
641012

5. (a) Date of birth : 06-06-2003


(b) Age on date of application : 18 years
6. Identification marks : [Link] ON LEFT HAND

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of Yes/No


loss of consciousness or giddiness from any cause ?

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

(e) 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 ?

(f) Do you suffer from any other disease or disability likely to Yes/No
cause your driving of a motor vehicle to be a source of danger
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


( G MAHAMITHRAA )

Note : - (1) An applicant who answers 'Yes' to any of the questions (a),(c),(d), (e) and (f) or 'No' to either
of the questions (b) 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.

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