Assam Schedule -LIX (Part IV) Form No. 2 (See Rule 10) FORM OF APPLICATION FOR THE GRANT OR RENEWAL OF LEARNERS LICENCE To, The Licensing Authority ............................................................................... Passport size ............................................................................... Photograph I hereby apply for a licence authorising me to drive as a learner, the following motor Vehicle(s). (a) Motor cycle without gear (b) Motor cycle with gear (c) Invalid carriage (d) Light motor vehicle (e) Medium passenger motor vehicle (f) Medium goods vehicle (g) Heavy passenger motor vehicle (h) Heavy goods vehicle (i) Road roller (j) Motor vehicle of the following description ........................................................................................................................................................................ ........................................................................................................................................................................ Particulars to be furnished by the Applicant 1. Full Name : 2. Son/ Wife/ Daughter of : 3. Permanent Address : (Proof to be enclosed) 4. Temporary Address : 5. Date of Birth (Proof to be enclosed) : 6. Educational qualification : 7. Identification mark(s) : 1. 2. 8. Optional Blood Group : RH factor 9. I hold an effective driving licence to drive (a) Motor Cycle/ : Official Address (if any) : light motor vehicle/ medium passenger motor vehicle/ medium goods vehicle with effect from 10. Particulars of any driving licence previously held by : applicant. Whether it was cancelled and is so, for what reason? 11. Particulars of any learner's licence previously held by : applicant in respect of the description of vehicle to which the applicant has applied. 12. Have you been disqualified for holding or obtaining driving : licence or learners licence if so, for what reasons 13. I enclose 3 copies of my recent photograph (Photograph to : be the size of the centimeters by six cms). 14. I enclosed medical fitness certificate dated .......................................... issued by (doctor) ................................ ..................................................................................................................................................................... 15. I have submitted along with my earlier applicable for : learner's licence/ I enclose the written consent to parent/guardian (in the case of applicant being a minor) 16. I enclose driving certificate dated ............................... issued by ..................................................................... (Name and address of the driving school) 17. I have paid the fee of : Rs. 18. I am exempted from the Medical test under rules 6 of : (Central Motor Vehicle Rules 1989) 19. I am exempted from the preliminary test under Rules 11(2) : of Central Motor Vehicle Rules 1989. ..................................................................................................................................................................... *Strike out whichever is inapplicable Date : ......................................... Signature or thumb impression of applicant Specimen signature or thumb impression of the applicant. 1. 2.
