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 Motor cycle above 50cc B) C) Light Motor Vehicle (includes Cars & Jeeps) Transport Vehicle D) 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) 2. Son/Daughter/Wife of 3. SEX MALE FEMALE 4. ADDRESS PERMANENT TEMPORARY Pincode 5. DATE OF BIRTH DD MM YYYY 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____________________________________________. I have submitted along with my application for learner's licence the written13. Yes No consent of parent/guardian I have submitted along with the application for learner's licence/I enclose the 14. Yes No medical fitness certificate I am exempted from the medical test under Rule 6 of the Central Motor 15. Yes No Vehicle Rules 1989 I am exempted from primary test under rule 11(2) of the Central Motor Vehicle 16. Yes No Rules 1989 I hereby declare that to the best of my knowledge and belief the particulars Yes Nogiven above are true. Note:Strike out whichever is inapplicable. Signature/Thumb Impression of applicant CERTIFICATE OF TEST OF COMPETENCE 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: Passed Failed Absent If failed Reasons for failure Name of Testing Autority Code Signature of the Testing Authority
