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The document is an application for a physical fitness declaration by Anil Kumar Singh, including personal details such as name, address, date of birth, and identification marks. It contains a series of health-related questions to assess the applicant's fitness for driving, all of which he answered negatively except for the vision question, which he answered affirmatively. The application must be submitted with a Medical Certificate in Form 1-A.

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48 views1 page

Document 1

The document is an application for a physical fitness declaration by Anil Kumar Singh, including personal details such as name, address, date of birth, and identification marks. It contains a series of health-related questions to assess the applicant's fitness for driving, all of which he answered negatively except for the vision question, which he answered affirmatively. The application must be submitted with a Medical Certificate in Form 1-A.

Uploaded by

anil
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We take content rights seriously. If you suspect this is your content, claim it here.
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Appl No:3868951724 Dt:18-10- CMV FORM 1

2024 [See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : ANIL KUMAR SINGH

2. Father's Name : JAYSHANKAR SINGH

3.Permanent address : J Tower 802, Arihant Abode


Plot No.- GH 4B Sector-10, Greater Noida West Ve
Baidpura Gautam Buddha Nagar Uttar Pradesh
203207

4.Temporary address : J Tower 802, Arihant Abode


Plot No.- GH 4B Sector-10, Greater Noida West Ve
Official address (if any)
Baidpura Gautam Buddha Nagar Uttar Pradesh
203207

5. (a) Date of birth : 10-02-1991


(b) Age on date of application : 33 years
6. Identification marks : 1.BONES IN RIGHT NOSE
2.SCRATCH ON RIGHT HAND

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of 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
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 No
from any defect in movement, control or muscular power of either
arm or leg ?

(d) Do you suffer from night blindness ? 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 No
hearing aid) the ordinary sound signal ?

(f) Do you suffer from any other disease or disability likely to 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. verified through Aadhaar
authentication

Signature or thumb impression of the applicant


( ANIL KUMAR SINGH )

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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