FORM 4 A [See Rule 14 (2)] [See Rules 5,7,10(a) and 14(b)] FORM OF APPLICATION FOR ISSUE OF INTERNATIONAL DRIVING PERMIT TO DRIVE A MOTOR VEHICLE IN OTHER COUNTRIES To The Licensing Authority ___________________ ___________________ I apply for an International Driving Permit to enable me to drive vehicles of the following categories: CATEGORIES OF VEHICLES FOR WHICH THE PERMIT IS APPLIED FOR A. Motor cycles Category L1 and Category L2 B. Motor Vehicles, other than those in Category (A) above, having a permissible maximum mass / weight not exceeding 3,500 KG (7700 lb) and not more than eight sets in addition to the driver's seat in Category M1 C. Motor Vehicles used for the carriage of goods and whose permissible maximum mass / weight exceeds 3,500 KG (7700 lb); D. Motor Vehicles used for the carriage of passengers and having more than eight seats in addition to the driver's seat; E. Combination of vehicles of which the driving is in a category or categories for which the driver is Licensed (B and or C and or D), but which are not themselves in that categories. PARTICULARS TO BE FURNISHED BY APPLICANT 1. Name .......................... (Surname) (Middle Name) (First Name) 2. Father's / Husband's Name .......................... 3. Place of Birth and country (proof to be entered) .......................... 4. Address: (a) Present .......................... (b) .......................... 5. Date of Birth (Proof to be enclosed) .......................... 6. Educational Qualification .......................... 7. Identification Marls .......................... 8. Blood Group / RH Factor .......................... 9. Have you previously held international Driving Permit ? If so, give details. .......................... 10. Particulars and date of every conviction which has been ordered to be endorsed on an driving license held by the applicant .......................... 11. Have you been disqualified for obtaining a driving license to drive ? If so, for what reason ? .......................... 12. Have you been subjected to a driving test as to your fitness or ability to drive a vehicle in respect of which a driving license is applied for ? if so, give the following details: .......................... Date of Test Testing Authority Result of Test (1) (2) (3) (4) 13. I enclose three copies of my recent passport size photograph. 14. I enclose the copy of driving license No ______________ dated _____________________ issued by __________________ Valid upto ________________________ 15. I enclose a medical certificate in form 1A. 16. I have paid a fee of Rs. __________________________ I hereby declare that the particulars given above are true to the best of my knowledge and belief. Signature / Thumb Impression of Applicant Date: _________________ Strike out whichever is inapplicable
