Medical Checkup For Pdvl !!hot!! ◎ [PLUS]

☐ – Reason: ________________________________________ 7. DECLARATION Applicant’s Declaration: I declare that the information given above is true and complete. I consent to this report being submitted to the relevant licensing authority.

You can copy and paste this template into a word processor or present it to a licensed clinic. To be completed by a Registered Medical Practitioner 1. PERSONAL INFORMATION | Field | Details | | :--- | :--- | | Full Name | [Last Name, First Name] | | NRIC / FIN No. | [S1234567A / G1234567X] | | Date of Birth (DD/MM/YYYY) | [01/01/1980] | | Gender | [ ] Male [ ] Female | | Contact Number | [9123 4567] | | Driving Experience (Years) | [e.g., 10 years] | 2. MEDICAL HISTORY (To be completed by applicant & verified by doctor) Does the applicant have a history of any of the following? (Please tick) medical checkup for pdvl

Signature of Applicant: ________________________ Date: ____________ ☐ – Reason: ________________________________________ 7

I have examined the above-named person and certify that, to the best of my knowledge, the findings are accurate. I have explained any restrictions or treatments required. You can copy and paste this template into