| . | |
| I, Sri / Smt / Kumari | ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
| Son/Wife/Daughter of | ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
| a. D.L.Number | ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() | b. Date of Issue | ![]() DD
![]() MM
![]() ![]() ![]() YYYY |
| e. Class of vehicle | ![]() | Motor cycle upto 50 cc | ![]() | Motor Cycle above 50 cc |
| Authorised to drive | ![]() |
Light motor vechicle | ![]() | Transport vehicle |
![]() | Invalid carriage | ![]() | Road Roller | |
![]() | Any other Category | ![]() (Specify the category in the box) |
| g. ADDRESS | PERMANENT | TEMPORARY |
| Door No. | ![]() | ![]() |
| Village/Town/City | ![]() | ![]() |
| Mandal | ![]() | ![]() |
| District | ![]() | ![]() |
| Pincode | ![]() ![]() ![]() ![]() ![]() ![]() |
![]() ![]() ![]() ![]() ![]() ![]() |
No
If not, Reasons___________________________________
No 
| Signature / Thumb impression of Applicant |