Eye Test

FOR DRIVING

CERTIFICATE FOR VISUAL STANDARDSthe certificate)

(see instuctions overleaf before filling up
Ihaveexamined Shri DALVIN VARGHESE ***************** aged...yeals..
and his/her visual standards are as follows:
Photograph of the candidate
(To be signed upon by the Ophthalmologist)
Dr. ROSAMMA,
M.B.B.S, M.S.(
1. Visual Acuity
Consultant
Keg. NO:1qT
Visual A. Axis
B. Cyl
Acuity Unaided Sph C. Binocular
Corrected Corrected

RE
LE
l Night blindness
Il Squint
V Field(Degrees)Horizontal
*************** ******* ******* VerticalA . J4
V Fundus: *******.... RE
Any other significant ocular morbidity i . u . ********************* ********** *
Candidate is Eit/Ufitto drive a Category 1/ vehicle.

Unfit due to criteria .... . ..... .mentioned above.
Cateaory-l means Non Transport Vehicles which include Motor Cycles, Motor Cars, etc. specified as such in Central
Gcvei nment Notification No.S.O.1248E)deted 5th Noverier 2004 as non-transport
Category-ll means Transport vehicles which include Autorickshaws, Taxis, Stage cariages, Contract Cariages
Goods cariages, Private Service Vehicles etc. specified as such in the said Notification.
24.L.
LIN
Signature of the candidate: Signature of Ophthalmologist
Place: SRTO, ANGAMALI E Seal
Date: 0442-2020 Dr. ROSAMMA }

SE
2|12/202b Date. M.B.B.S., M.S.(Ophth), DOMS

Consultant Ophthalmic Surgeon
AL
1M A
Reg. No: 13195
Appl No:3570111820 Di:01-12-2020
FORM 1-A 357Oiii820
e e rules 5(1).(3),7,100a), 14(d), and 18(d)]

MEDICAL CERTIFICATE
l o be filled in by a registered medical practiioner annointed for the purpose by the state (Government or person
authorised in this behalí by the State Government referred to under sub section (3) of section 8)
1.Name of the applicant DALVIN VARGHESE

2. Identification marks
1.A BLACK MOLE ON THE NECKK
2.A BLACK MOLE ON THE LEFT
FOOT
3.
(a) Does the applicant, to the best of your judgment, suffer from any defect
of vision? lf so, has it been corrected by suitable YesTNd
spectacles
(b)in your opinion, is he able to distinguish with his eye sight at a distance of 25 Vés/No
metres in good day light a motor car number
plate ?
(c) In your opinion, does the applicant suffer from a degree of deafness YestN
which would prevent his hearing the ordinary sound signals
(d) In your opinion, does the applicant suffer from night blindness ? YesTNo
(e) Has the applicant any defect or
deformity or loss of member which would
interfere with the efficient performance of his duties as a driver? lif so, givVe Yes7N
your reasons in details.
(1) 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 desires that the ***********************
information may be noted in his driving licence).

Declaration made by the applicant in Form 1 as to his physical fitness is attached
Certificate of Medical Fitness

I certify that
i) that I have personally examined the applicant Shri/Smt/Kum: DALVIN VARGHESE
i) that while examiningthe applicant I have directed special attention to herihis distant vision;
i) while examining the aplicant, I have directed special attention tohis/ker tearing ability, the conditon of the ams,
legs, hands and joints of both extremities of the applicant
v) Ihavepersonally examined the applicant for reacion time, side vislon and glare recovery, (applicable in case of
persons applying for a licence to drive goods carriage carrying goods of dangerour or hazardous nature to
human life); and
() Applicant's colour vision has been tested using standard ishihara chart and the applicant has not been found
suffering from severe or total colgurblindness
And, therefore, I certify that, to the b stóf my judgmernt, he is medically ftUnet-fit to hold a drivingJjcende.
Theapplicant isnot medically,fit to'hold a licence for the following reasons:
Signature
1. Name and designation ofthe of Medicaí Officer/ Practitioner
(Seal)
Registration Number of Medical Officer
Dr. ROSAMM
M.B.B.S., M.S.(O
CLIN
R20
Datc2aSignature or thumb impression of the candidate Dr. ROSAMMA
M.B.B.S., M.S.(Ophh),
(DALVIN VARGHESE Consultant Ophthaimic Surg
Consul Baie912/2020 VGAM
AMA
Reg. Note:-1. The medical Officer shatl Reg. No:part
àffikhissignature over the photograph affixed in such a manner that
of his signature is upon the photograph and part on the certificate.
13195
2. Dumb persons without deafness may be granted a valid certificate of driving licence for
non-transport vehicle.

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FOR DRIVING

CERTIFICATE FOR VISUAL STANDARDSthe certificate)

Any other significant ocular morbidity i . u . *********** *

Candidate is Eit/Ufitto drive a Category 1/ vehicle.

Date: 0442-2020 Dr. ROSAMMA }

2|12/202b Date. M.B.B.S., M.S.(Ophth), DOMS

e e rules 5(1).(3),7,100a), 14(d), and 18(d)]

1.Name of the applicant DALVIN VARGHESE

information may be noted in his driving licence).

Certificate of Medical Fitness

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