Driving Licence Medical Report Form

To drive you must meet certain medical fi tness standards. For this purpose vehicles are classed as Group 1 and Group 2.

If you are applying for a vehicle in both Groups (See note 2 overleaf) please tick Group 1 and 2 on this form. Where an applicant

meets the medical criteria for Group 2 vehicles, they will automatically meet the medical criteria for Group 1 vehicles.

Driver number

First name(s)

Surname

Address 1

Date of birth

Day Month Year

PPSN

(Please X the appropriate box)

I wish to undergo a medical examination on foot of my application for a learner permit/driving licence as required

by the Road Traffi c Acts. (See note 1 overleaf).

My application is for a driving licence/learner permit as a driver of a Group 1

or Group 2 vehicle.

Signature

(To be signed in the presence of your Medical Practitioner)

This form must be submitted to National Driver Licence Service with an application for a driving licence/learner permit

within one month of its completion by a Medical Practitioner.

VEHICLES IN GROUP 1 AND GROUP 2