Form 4 (see rule14) Form of Application for License to Drive Motor Vehicle Space for photograph of the Tosize five The Licensing Authority centimeters by six centimeters I 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 carriage (d) Light motor vehicle (e) Medium goods vehicle (f) Medium passenger motor vehicle (g) Heavy goods Vehicle (h) Heavy passenger motor vehicle (i) Road roller (j) Motor vehicle of the following description Particular to be furnished by the Applicant 1. Name ................................................................................................................................................................................... 2. Son/Wife/Daughter.............................................................................................................................................................. 3. Permanent Address ............................................................................................................................................................. (Proof to be enclosed) 4. Temporary address/Official address(if any) ........................................................................................................................ 5. Date of Birth....................................................................................................................................................................... (Proof to be enclosed) 6. Education qualification........................................................................................................................................................ 7. Identification Mark.............................................................................................................................................................. (1)______________________________________ (2)______________________________________ 8. Blood Group and RH 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, far 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 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 enclosed 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 enclosed the Learner's No.........................dated..........................issued by Licensing Authority. 15. I enclosed the Driving Certificate No.........................dated..........................issued 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 my 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 Rule 1989. 19. I am exempted from preliminary test under rule 11(2)of the Central Motor Vehicles Rule 1989. 20. I have paid the fee of the rupees ................................................................................................................................... I here by declare that to the best of my knowledge and belief the particulars given above are true.. 2 Note.-Strike out whichever is inapplicable. Signature/Thumb impression of applicant Date----------------------- Certificate of test of competence to drive The applicant has passed the test prescribed under rule 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
