APPLICATION FORM FOR Licence TO DRIVE A MOTOR VEHICLE
FORM - 4 (See rule - 14)
To
The Licencing Authority,


I enclosed Learners Licence No Dt. Issued by L.A I hereby apply for a Licence authorising me to drive the following vehicles ( Tick at the appropriate box)


A) Motor cycle below 50cc
B) Motor cycle above 50cc
C) Light Motor Vehicle (includes Cars & Jeeps)
D) Transport Vehicle
E) Road Roller
F) Invalid Carriage (incase of physically handicapped applicants)
G) Any Other Category (Specify the category in the box)

(Please fill the following particulars in CAPITAL Letters only)
1.   FULL NAME (Leave one Space between first and last name)

2.   Son/Daughter/Wife of


3.   SEX MALE FEMALE
4.   ADDRESS PERMANENT TEMPORARY
    Door No.
    Village/town/city
    Mandal
    District
    Pincode
5. DATE OF BIRTH
6. EDUCATIONAL QUALIFICATION    
7.IDENTIFICATION MARKS 1  
  2  
8. (Optional) : BLOOD GROUP & Rh FACTOR

Disclaimer : The applicant is solely responsible for any medical complications that may arise due to wrong declaration of the Blood group.

9. Particulars and date of every conviction which has been ordered to be endorsed on
any Licence held by the applicant.

10. Particulars of disqualification of the applicant from obtaining a Licence to drive,and reasons for it.


Applicant's declaration


12. I enclose the Driving Certificate No. Dated
Issued by
13. I have submitted along with my application for learner's Licence the written consent of parent/guardian Yes No
14. I have submitted along with the application for learner's Licence/I enclose the medical fitness certificate Yes No
15. I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules 1989 Yes No
16. I am exempted from primary test under rule 11(2) of the Central Motor Vehicle Rules 1989 Yes No
  I hereby declare that to the best of my knowledge and belief the particulars given above are true. Yes No

Note:Strike out whichever is inapplicable.

Signature/Thumb Impression of applicant.


CERTIFICATE OF TEST OF COMPETENCE


The applicant has passed the test prescribed under rule 15 of the CMV rules, 1989.
 
The test was conducted on vehicle with Reg.No. on
The applicant has passed the test prescribed under rule 15 of the CMV rules, 1989.
Result of the Test: Absent Passed Failed
 
If failed Reasons for failure
Name of Testing Autority
Code
Signature of the Testing
Authority