FORM - 4 (See rule 4) Form of Application for License to drive a Motor Vehicle To. The Licensing Authority _____________________________ Space for _____________________________ photograph of the size five I apply for license to enable me to drive vehicle of the following Description: centimeters by six centimeters (a) Motor Cycle without Gear - (b) Motor Cycle with Gear - (c) Invalid Carriage - (d) Light motor vehicle - (e) Medium goods vehicle - (f) Medium passengers motor Vehicle - (g) Heavy Goods Vehicle - (h) Heavy passengers motor vehicle - (i) Road Roller - (j) Motor vehicle of the following description -- Particulars to be furnished by the Applicant 1. Name ......................... 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 Marks (1) ..... .................... (2) ......................... 8. Blood Group and R. H. factor. ......................... 9. Have you previously held ......................... 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. 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 or ability to drive a vehicle in respect of which a license 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 enclose three copies of my recent photograph of the size five centimeters into six centimeters (where laminated card is used, no photograph are required). 14. I enclose the Learner's License No. .............. dated ....... 15. I enclose the driving Certificate No. .............. dated ....... issues by ......................... 16. I have submitted along with my application for Learner's License the written consent of parent ' guardian. 17. I have submitted along with the application for Learner's License / I enclose the Medical Fitness Certificate. 18. I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules, 1989. 19. I am exempted from preliminary test under Rule 11(2) of the Central Motor Vehicle Rules, 1989. 20. I have paid the fee of rupees ___________________________________________________. I hereby declare that to the best of my knowledge belief the particulars given above are true. issued by the Licensing Authority ......................... 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 Vehicle 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 Strike out whichever is inapplicable.
