FORM I
[See Rule 5 (2)]
APPLICATION-CUM-DECLARATION AS TO PHYSICAL FITNESS
1. Name of the applicant __________________________________
2. Son/wife/daughter of __________________________________
3. Permanent address __________________________________
4. Temporary address __________________________________
Official address(if any) __________________________________
5. (a) Date of Birth __________________________________
(b) Age on the date of application __________________________________
6. Identification marks (1) _______________________________
(2) _______________________________
Declaration
(a) Do you suffer from epilepsy or from Sudden attacks of loss of consciousness or Giddiness from any cause?
(b) Are you able to distinguish with each eye (or if you have held a driving license 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 applicant is for driving a light motor vehicle other than a transport vehicle fitted with an outside mirror on the steering wheel side) or (with side) or with one eye, at distance of 25 meters in good day light with glasses, if warn motor car number plate ?
(c) Have you lost either hand or foot or are Yes/No
you suffering from any defect of muscular power of either arm or leg ?
(d) Can you readily distinguish the pigmentary Yes/No
colours, red and green ?
(e) Do you suffer from night blindness ? Yes/No
(f) Are you so deaf so as to be unable to hear Yes/No
(and if the application is for driving a light
motor vehicle, with or without hearing aid)
the ordinary sound signal ?
(g) Do you suffer from any other disease or Yes/No
disability likely to cause your driving of a motor vehicle to be a source of danger to the public, if so, give details ?
Yes/No
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

Notes:- (1) An applicant who answers “yes” to any of the question (a), (c), (e), (f), and
(g) or “No” to either of the questions (b) and (d) should amplify his answers with full particulars a may be required to give further information relating thereto.
(2) This declaration is to be submitted invariably with medical certificate in Form IA.
Please pay the cost of this form at the concern RTO Rs. 5.00 Printed from www.goatransport.com