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Gopal Bhoi has applied for a physical fitness certificate. He provides his name, father's name, permanent and temporary addresses, date of birth as 18-06-1989 making him 30 years old, and a declaration of various health factors. He declares that he does not suffer from epilepsy, sudden loss of consciousness, giddiness, or night blindness. He affirms that he can distinguish license plates at 25 meters and does not have any loss of hands, feet, or defects in arm/leg movement. He also does not suffer from deafness or other diseases that could endanger others during driving. Gopal signs declaring this information is true to the best of his knowledge.

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49 views1 page

GP 3

Gopal Bhoi has applied for a physical fitness certificate. He provides his name, father's name, permanent and temporary addresses, date of birth as 18-06-1989 making him 30 years old, and a declaration of various health factors. He declares that he does not suffer from epilepsy, sudden loss of consciousness, giddiness, or night blindness. He affirms that he can distinguish license plates at 25 meters and does not have any loss of hands, feet, or defects in arm/leg movement. He also does not suffer from deafness or other diseases that could endanger others during driving. Gopal signs declaring this information is true to the best of his knowledge.

Uploaded by

Śŗíķańt Máhaŕaňà
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Appl No:1051462220 Dt:12-03-2020 CMV FORM 1

[See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : GOPAL BHOI

2. Father's Name : LILAMBAR BHOI

3.Permanent address :
Khariar (NAC)
KHARIAR,Nuapada,OD
766107

4.Temporary address :
Official address (if any) Khariar (NAC)
KHARIAR,Nuapada,OD
766107

5. (a) Date of birth : 18-06-1989


(b) Age on date of application : 30 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) 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


( GOPAL BHOI )

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.

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