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Coding Analysis

This document contains an application for a license to drive a commercial motor vehicle. It includes details of the applicant such as name, age, address, and identification marks. It also contains a declaration where the applicant must answer yes or no to questions regarding their physical fitness to drive, including whether they have any medical conditions like epilepsy, blindness, deafness, or disabilities that could impact their ability to drive safely. The applicant must sign the declaration, and may need to provide further medical information if they answer yes to certain questions. This declaration must be submitted along with a Medical Certificate form.

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abisheksundaram00
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23 views1 page

Coding Analysis

This document contains an application for a license to drive a commercial motor vehicle. It includes details of the applicant such as name, age, address, and identification marks. It also contains a declaration where the applicant must answer yes or no to questions regarding their physical fitness to drive, including whether they have any medical conditions like epilepsy, blindness, deafness, or disabilities that could impact their ability to drive safely. The applicant must sign the declaration, and may need to provide further medical information if they answer yes to certain questions. This declaration must be submitted along with a Medical Certificate form.

Uploaded by

abisheksundaram00
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Appl No:3834085023 Dt:05-10- CMV FORM 1

2023 [See rule 5(2)]


Application –cum-declaration as to the physical fitness

1.Name of the applicant : SHANKAR A T

2. Guardian Name : ARUNACHALAM B

3.Permanent address : No 74/104


Chinna Vedampatti Lane Poomarket
Coimbatore Coimbatore Tamil Nadu
641001

4.Temporary address : No 74/104


Chinna Vedampatti Lane Poomarket
Official address (if any)
Coimbatore Coimbatore Tamil Nadu
641001

5. (a) Date of birth : 14-01-2004


(b) Age on date of application : 19 years
6. Identification marks :

Declaration :

(a) Do you suffer from epilepsy, or from sudden attacks of Yes/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/No
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 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


( SHANKAR A T )

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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