FORM 4 [See Rule 54] [See Rules 5,7,10(a) and 14(b)] Form of Application for License to drive a Motor Vehicle To The Licensing Authority ___________________ ___________________ I hereby apply for a license to enable me to drive vehicles of . the following description: (a) Motor Cycle without gear, (b) Motor Cycle with gear, (c) Invalid Carriages, (d) Light Motor, (e) Medium Goods Vehicle, (f) Medium Passenger motor Vehicle, (g) Heavy Goods Vehicle, (h) Heavy Passenger Motor Vehicle, (i) Road Roller, (j) Motor Vehicles of the following description Particulars to be furnished by the Applicant 1. Full Name of the Applicant ________________________________________________ 2. Son/Wife/Daughter of ________________________________________________ 3. Permanent Address ________________________________________________ (Proof to be enclosed) ________________________________________________ 4. Temporary Address / Official ________________________________________________ Address if any ________________________________________________ 5. Date of Birth ________________________________________________ (Proof to be enclosed) 6. Educational Qualification ________________________________________________ 7. Identification Mark ________________________________________________ 8. Blood Group and RH factor ________________________________________________ 9. Have you previously hold driving license if so, give details 10. Particulars and date of every conviction which has been ordered to be endorsed on any license held by the applicant Space for Photograph of the Size Five Centimeters by Six Centimeters 11. Have you been disqualified for obtaining a license to drive ? If so, for what reason ? 12 Have you been subjected to driving test as to your fitness of ability to drive vehicle in respect of which a license to drive is applied for ? If so, give details: Date of Test Testing Authority Result of Test 1. 2. 3. 4. 13. I enclose 3 copies of my recent photograph to be size of five centimeters by six centimeters. (Where Laminated card is used no photograph are required. 14. I enclose the Learner's License No _________________ Dated _____________ issued by Licensing Authority. 15. I enclose the Driving Certificate No _________________ Dated _____________ 16. I have submitted along with my application for Learner's license the written consent of parent /guardian (in case of applicant being minor). 17. I have submitted along with my application for Learner's license I enclose the medical fitness certificate 18. I am exempted fro the medical test under rule 6 of Central motor / Vehicle rule 1989. 19. I am exempted from the preliminary test under Rule 11(2) of Central Motor Vehicles Rules 1989. 20. I have paid the fee of rupees. __________________________ I hereby declare that to best of my knowledge and belief the particulars given above are true. Note:- Strike out whichever is inapplicable Signature / Thumb Impression of applicant Date Certificate of Test Competence to Drive The applicant had passed the test prescribed under the rule of the Central Motor Vehicles Rules 1989. The test was conducted on (the registration mark and description of the vehicle ___________ (on date) The applicant had failed in the test. (the details of the deficiencies to be listed out) Date Signature of Testing Authority Full Name and Designation Two Specimen Signatures of Applicant Note:- Strike out whichever inapplicable
