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CMV Form 1: Physical Fitness Declaration

The document is an application for a physical fitness declaration by Shivraj Sah, who is 19 years old and resides in Jalpaiguri, West Bengal. It includes personal details, identification marks, and a series of health-related questions regarding the applicant's ability to drive safely. The applicant must declare the truthfulness of the information provided and may need to submit additional medical documentation if certain health conditions are indicated.

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4 views1 page

CMV Form 1: Physical Fitness Declaration

The document is an application for a physical fitness declaration by Shivraj Sah, who is 19 years old and resides in Jalpaiguri, West Bengal. It includes personal details, identification marks, and a series of health-related questions regarding the applicant's ability to drive safely. The applicant must declare the truthfulness of the information provided and may need to submit additional medical documentation if certain health conditions are indicated.

Uploaded by

vishalkrprasad478
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:1806466825 Dt:10-05- CMV FORM 1

2025 [See rule 5(2)]


Application –cum-declaration as to the physical fitness

[Link] of the applicant : SHIVRAJ SAH

2. Guardian Name : SANTOSH SAH

[Link] address :
south santinagar Dabgram
Dabgram (P) Rajganj Jalpaiguri West Bengal
734004

[Link] address :
south santinagar Dabgram
Official address (if any)
Dabgram (P) Rajganj Jalpaiguri West Bengal
734004

5. (a) Date of birth : 20-07-2005


(b) Age on date of application : 19 years
6. Identification marks : [Link] ON FORE HEAD

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


( SHIVRAJ SAH )

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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