Scribd Logo
Upload

Welcome to Scribd!

  • 25 views

    Declaration 230831 091957

    Uploaded by

    Ikra husn
    This document contains an application for a driving license from Ikhrash Hussain. It includes his personal details like name, address, date of birth. It also contains a self-declaration where he answers questions about his physical fitness like whether he has epilepsy, loss of vision, hearing impairment etc. He answers "no" to questions about medical conditions and "yes" to having proper vision. The document needs to be submitted with a medical certificate to verify the applicant's physical fitness.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Declaration 230831 091957

    Uploaded by

    Ikra husn
    25 views1 page
    This document contains an application for a driving license from Ikhrash Hussain. It includes his personal details like name, address, date of birth. It also contains a self-declaration where he answers questions about his physical fitness like whether he has epilepsy, loss of vision, hearing impairment etc. He answers "no" to questions about medical conditions and "yes" to having proper vision. The document needs to be submitted with a medical certificate to verify the applicant's physical fitness.

    Original Description:

    Declaration template for driving license

    Original Title

    Declaration_230831_091957

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains an application for a driving license from Ikhrash Hussain. It includes his personal details like name, address, date of birth. It also contains a self-declaration where he answers questions about his physical fitness like whether he has epilepsy, loss of vision, hearing impairment etc. He answers "no" to questions about medical conditions and "yes" to having proper vision. The document needs to be submitted with a medical certificate to verify the applicant's physical fitness.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    25 views1 page

    Declaration 230831 091957

    Uploaded by

    Ikra husn
    This document contains an application for a driving license from Ikhrash Hussain. It includes his personal details like name, address, date of birth. It also contains a self-declaration where he answers questions about his physical fitness like whether he has epilepsy, loss of vision, hearing impairment etc. He answers "no" to questions about medical conditions and "yes" to having proper vision. The document needs to be submitted with a medical certificate to verify the applicant's physical fitness.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Appl No:3207696323 Dt:21-08- CMV FORM 1

    2023 [See rule 5(2)]


    Application –cum-declaration as to the physical fitness

    1.Name of the applicant : IKHRASH HUSSAIN

    2. Father's Name : ABDUL BASIT RUKNADDIN

    3.Permanent address : KTFF HEIGHTS APARTMENT FLAT NO 002


    AZAD NAGAR 7TH CROSS AZAD NAGAR 7TH CROSS ABU
    HAN
    Bhatkal Uttara Kannada Karnataka
    581320

    4.Temporary address : BAITUL NAQIB MADINA


    COLONY JAMIA ABAD ROAD
    Official address (if any)
    Bhatkal,Uttara Kannada,KA
    581320

    5. (a) Date of birth : 05-12-2003


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

    Declaration :

    (a) Do you suffer from epilepsy, or from sudden attacks of 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
    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 No
    from any defect in movement, control or muscular power of either
    arm or leg ?

    (d) Do you suffer from night blindness ? 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 No
    hearing aid) the ordinary sound signal ?

    (f) Do you suffer from any other disease or disability likely to 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. verified through Aadhaar
    authentication

    Signature or thumb impression of the applicant


    ( IKHRASH HUSSAIN )

    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.

    You might also like