(To be filled at the time of applying for Permanent Licence) FORM-4 FORM OF APPLICATION FOR LICENCE TO DRIVE A MOTOR VEHICLE [See Rule 14] To The Licensing Authority I apply for a licence to enable me to drive vehicles of the following description : (a) Motor cycle without gear (b) Motor cycle with gear (c) Invalid carriage (d) Light motor vehicle (e) Medium goods vehicle (f) Medium passenger motor vehicle (h) Heavy goods vehicle (i) Road roller (j) Motor vehicle of the following description : PARTICUALRS TO BE FURNISHED BY THE APPLICATION 1. Name of the Applicant ................................................................................................... 2. Son/Wife/Daughter of .................................................................................................... 3. Permanent address (Proof to be enclosed)...................................................................... 4. Date of birth (Proof to be enclosed) ............................................................................... 6. Education Qualification.................................................................................................. 7. Identification marks........................................................................................................ (1) ............................................................ (2) ................................................................. 8. Optional.................................................................... Blood Group ............................................................. RH Factor ................................................................. 9. Have you previously held driving licence. If so give details ......................................... 10. Particulars and date of every conviction which has been ordered to be endorsed to any licence held by the applicant.................................................................................... 11. Have you been disqualified for obtaining a licence to drive ? If so, for what reasons .................................................................................................... 12. Have you been subjected to a driving test as to your fitness or ability to drive a vehicle in respect of which a licence to drive is applied for ? If so give the following details : Date of Test Testing Authority Result of Test 1. 2. 3. 4. 13. I have enclosed three copies of my recent photographs of the five centimeters into six centimeters (where laminated card is used no photographs are required) 14. I have enclosed the learner's licence No.............. dated........... issued by licensing authority 15. I have enclosed the driving certificate No. dated........ issued by ................................... ........................................................................................................................................ 16. I have submitted my application for learner's licence alongwith the written consent of my parent/guardian. 17. I have submitted alongwith the application for learner's licence/I enclose the medical fitness certificate. 18. I am exempted from medical test under rule 6 of the Central Motor Vehicles Rules, 1989. 19. I am exempted from preliminary test under rule 11(2) of the Central Motor Vehicles Rules, 1989. 20. I hereby declare that the particulars given above are true to the best of my knowledge and belief. Note : Strike out whichever is inapplicable. Date ___________ Signature/Thumb impression of Applicant CERTIFICATE OF TEST OF COMPETENCE TO DRIVE The applicant has passed the test prescribed under Rule 15 of the Central Motor vehicles Rules, 1989. The test was conducted on, (here enter the registration mark and description of the vehicle ___________on (date)_____________ The applicant has failed in the test (The details) of the deficiency to be listed out). Date ___________ Signature of Testing Authority Full name and designation Two Specimen signature of applicant 1. .................................................................2................................................................ *Strike out whichever is inapplicable
