FORM NO. 4 FORM FOR APPLICATION FOR LICENSE TO DRIVE A MOTOR VEHICLE. To The Licensing Authority ....................... .. I apply for a license to enable me to drive the vehicle of the following descriptions: (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 Vehicles of the following descriptions: .................................. ........ .......................... PARTICULARS TO BE FURNISHED BY THE APPLICANT (1) Name ................................. (2) Son/Wife/Daughter of .......................... Permanent Address .......................... . (Proof to be enclosed) .................... ..... . (3) Temporary Address, Official ....................... address (if any) : ............................. (5) Date of Birth (Proof to be enclosed) ................... .. (6) Educational Qualification: ........................ (7) Identification Marks: ........................... (8) Blood Group & RH Factor.......................... (9) Have you previously hold a Driving License, if so, give details: ........ .. .......... ........... ........... .... .. (10) Particulars and date of every conviction ...... ............ . which has been entered to be endorsed .................. .. on any license held by the applicant. .................. (11) Have you been disqualified for : ....................... obtaining a driving License? If so ..................... for what reason? ...................... (12) Have you been subjected to a driving: .................. test as to your fitness or ability ..................... .. to drive a vehicle as applied for? .................... (13) Date of Test Testing Authority Result of Test 1. 2. 3. 4. (14) I enclose three copies of my recent photograph (photograph) of the size 5 cms by 6 cms.(where laminated card is used no photographs are required) : .................. (15) I enclosed the Learner's License No. : .......... ......... .. (16) I enclose the Driving Certificate No...... ...... .. dated ...... . issued by .............................. . (17) I have submitted along with my application for Learner's License the written consent of my Parent/Guardian. .................. ........ (18) I have submitted along with the application for learner's license/I enclose the fitness Certificate. (19) I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Act, 1989. : ............................... (20) I am exempted from preliminary test under Rule 11(2) of the Central Motor Vehicle Act, 1989. : ............................. (21) I have paid the fees of Rs. ........................ I hereby declare to the best of my knowledge and belief the particulars given above are true. Strike out whichever is inapplicable. Dated : Signature/Thumb impression of the applicant Certificate of test competency to drive The applicant has passed the test prescribed under Rule 15 of the Central Motor Vehicle Act, 1989. The test was conducted (here enter the Registration Mark and description of the Vehicle) ... ...................................... .. ................................ .... .. The applicant has failed in the test. (The details of the deficiency to be listed out). Date :........ .. Signature of the testing authority Full Name and Designation Two specimen signature of the applicant, Strike out whichever is inapplicable.
