Form I-A
Medical Certificate
[see Rules 5(1), (3), 7,10(a), 14(d) and 18(d)]
(To be filled in by a registered medical practitioner appointed for the purpose by state Government or
person authorized in this behalf by the state government referred to under sub-section (8) of section 8 )
1. Name of the applicant:
2. Identification Marks : (1)
(2)
3. (a) Does the applicant to the best of your judgment
suffer from any defect of vision ?if so , has it
been corrected by suitable spectacle Yes/No
(b) Can the applicant to the best of your judgment readily distinguish the pigmentary colours, red and green? Yes/No
(c) In your opinion , is he able to distinguish with his eyesight at a distance of a distance of 25 meters
in good daylight a motor car number plate? Yes /No
(d) In your opinion does the applicant suffer from a degree of deafness which would prevent him
hearing the Ordinary sound signals? Yes/No
(e) In your opinion does the applicant suffer from night Blindness? Yes/No
(f) Has the applicant any defect or deformity or loss of Memory which would interfere with the efficient
Performance of his duties as a driver? If so, give Your reason in details Yes/No
(g)………………………………………………………… P T O
Optional
(a) Blood group of the applicant (if the applicant so desires that the information may be noted in his
driving licence).
(b) RH factor of the applicant (if the applicant so desired that the information may be noted in his
driving licence).
Declaration made by the applicant in form –I as to his physical fitness is attached.
I certify that I have personally examined the applicant ………………………………………………
…………………………………….I also certify that while examining the applicant , I have directed
special attention to the distant vision and hearing ability , the condition of the arms, legs, hands and joints of both extremities of the candidate and to the best of my judgment he is medically fit/not fit* to hold a driving license.
The applicant is not medically fit to hold a license for the following reason:-
Signature
1. Name and designation of the medical officer/ practitioner (Seal)
2. Registration Number of medical officer
Signature or thumb
Impression of the candidate……………………..
Date……………
Note: The Medical Officer shall affix his signature over the photograph affixed in a manner that part
of his signature is upon the photograph and part on the certificate.
Note: please pay the cost of this form at the concerned RTO Price: Rs. 5. 00 Printed from www.goatransport.com
Space for
passport size
photograph of
the applicant
……………………………………………………………………………………………………………………………………………………………………………………………….
OFFICE ENDORSEMENT
Number __________________ dated ____________________ Office of the _____________________
The cancellation of the entry of an agreement as requested above is recorded in this Office
registration record in Form 24 and Registration Certificate on _____________________ (date).
Signature of the Registering Authority
Dated __________________
To
………………………………………………………………………………………………………………………………………………………………………………………………….
(Name & address of the Financier)
By registered post or delivered under proper acknowledgement.
Price: Rs. 5.00
Please pay the cost of this form at concerned RTO Printed from www.goatransport.com