This document contains an application form for determining an applicant's physical fitness to drive. It requests information such as the applicant's name, address, date of birth, identification marks, and requires the applicant to declare whether they have any conditions that could impact their ability to drive safely, such as epilepsy, eyesight impairments, loss of limbs, hearing problems, or other disabilities. The applicant must sign declaring that their answers are true to the best of their knowledge.