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    Shrimad Bhagwat Katha By Bhai Shri Rameshbhai Oza | Haridwar Day-6

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    Shrimad Bhagwat Katha By Bhai Shri Rameshbhai Oza | Haridwar Day-6

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    Shrimad Bhagwat Katha By Bhai Shri Rameshbhai Oza | Haridwar Day-6

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
    159 views2 pages

    Combinepdf

    Uploaded by

    Shahil Kumar
    Shrimad Bhagwat Katha By Bhai Shri Rameshbhai Oza | Haridwar Day-6

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
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    Form 1 g [See Rules 5(2)] oe lication - Cum - declaration as to be physical fitness +. Name otapplicant 2. Son/Wite/Daughterof 3. Permanent Address 4. Temporary Address 5. Offical Address (itany) 6. (a) DateofBirh : Ee - (b) Age on date ct application : 7. Identification Marks 2 (1) 2) Declaration (@) Doyousutferfrom eplpsy or from sudden attacks of lose of giddiness from any cause? (ebype (0) Are you able to distinguish with each ‘eye (or if you have held a driving " ~nce to drive motor vehicle for @ period not less ...an five years and if you have lost the sigii of one eye after the sald period of five years and if the application Is for driving a light motor vehicle Yer/Noy other than a-transport vehicle fitted with an outside mirror on the sterring wheel side) or with one eye ata distance of 25 meters in good day light (with glasses, If worn) amotor car numberplate, . (2) Have you lost either hand or foot or are you suffering from any defect or muscular powerin No otherarmorleg? (4) Canyou readily distinguish the pigmentary colour, red andgreen? Yesi(Mo) (2) doyou sutferfrom bightblindless 7 (Neato () Ars you so deat as to be unable to hear (and ifthe application is for driving a light Motor Yes)No vehicle with or without gearing ete) the ord!nary sound signal’? 7 (g) do you sutfer from any other dieses or disability lIkely to cause your driving of a motor Yes}No vehicle tobe @ source of dangerto the public, itso give detalls, Cw | hereby declare that to the best of my knowledge and behalf the particulars given above and declaration must be there on are true (signature or érmb impression of the Applicant) FE , See Rul orm 1-4 [ ules hee 7, 10(a), "44 ang . 1. Toba filed in Dy. Fi ae Ical Certificat (d), inthis behait pea ical Pract e State Go) vernon oa 1d for the pup 1. Name ofappiicant: rm ovement of Phas, o 2. Identification Mark: teas x (1) P)> Dope (a) Does the appi 2 @pplicantto the best of yo gin le best of, tur udgementsuifer tom any detectot vision? Ne (b) Canthe ay icant t Y. = 5 thebestof Your geen ead cisnguish ne pigmentary cour es 19 {e) _Inyour opinion, is able to dist i in good oe lata his ee sight ata cstanceof28 motes eee {d) Inyour opinion does the pplicant sutter trom a degree of deatness which would prevent his wo hearing the otdinary sound signal. (6) Inyour opinion does the applicant sufterfromnightbiindness ? yao () Has the applicant any detect or deformity or loss of member which would interfere with the No #fficient performance of his duties as & driver 7t 90, give your reasons in detall. 8 Optional (a) blood Group and RH Factor i? may be noted inhis driving licenca) (ifthe applicant so desire that the information be given Declaration made by the applicantin form-1 as tohis physical fitness s attached, the applcent__ {Cortfy that have personally examined — exami jicant | have directed special attention to the distant vision and hearing abilly, the condtion aaa aia nands end olna of boh exterites ofthe candiala and tothe Best of my) ie is ‘radically fit/not tto hold a drving cence. judgement the applicantis not medically fit to hold a licence forthe folowing reason z= ] Signature 1, Name and Designation of the Medical officer / Practitioner (Seal) 2, Registration No. of Medical Officer shall ax hs signature over the photograph manner that part of he Note:The Mo the photograph and part on the cerificate.

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