APPLICATION FORM FOR LICENCE TO DRIVE A MOTOR VEHICLE FORM - 4 (See rule - 14) To The Licencing Authority, _______________________ I enclosed Learners Licence No.____________________Dt._________________issued by L.A._________________. I hereby apply for a Licence authorizing me to drive the following vehicles (Tick at the appropriate box) A) http://punjabtransport.nic.in/images/box3.jpg Motor cycle below 50cc B) http://punjabtransport.nic.in/images/box3.jpg Motor cycle above 50cc C) http://punjabtransport.nic.in/images/box3.jpg Light Motor Vehicle (includes Cars & Jeeps) D) http://punjabtransport.nic.in/images/box3.jpg Transport Vehicle E) http://punjabtransport.nic.in/images/box3.jpg Road Roller F) http://punjabtransport.nic.in/images/box3.jpg Invalid Carriage (incase of physically handicapped applicants) G) http://punjabtransport.nic.in/images/box3.jpg Any Other Category http://punjabtransport.nic.in/images/box4.jpg (Specify the category in the box) (Please fill the following particulars in CAPITAL Letters only) 1. FULL NAME (Leave one Space between first and last name) http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg 2. Son/Daughter/Wife of 3. SEX MALE http://punjabtransport.nic.in/images/box3.jpg FEMALE http://punjabtransport.nic.in/images/box3.jpg 4. ADDRESS PERMANENT TEMPORARY Door No. http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg Village/town/city http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg Mandal http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg District http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg Pin code http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg 5. DATE OF BIRTH http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg DD http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg MM http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg YYYY 6. EDUCATIONAL QUALIFICATION http://punjabtransport.nic.in/images/box5.JPG 7.IDENTIFICATION MARKS 1 http://punjabtransport.nic.in/images/box5.JPG 2 http://punjabtransport.nic.in/images/box5.JPG 8. (Optional) : BLOOD GROUP & Rh FACTOR http://punjabtransport.nic.in/images/box3.JPG http://punjabtransport.nic.in/images/box3.JPG http://punjabtransport.nic.in/images/box3.JPG http://punjabtransport.nic.in/images/box3.JPG Disclaimer : The applicant is solely responsible for any medical complications that may arise due to wrong declaration of the Blood group. 9. Particulars and date of every conviction which has been ordered to be endorsed on __________________ any license held by the applicant. 10. Particulars of disqualification of the applicant from obtaining a license to drive, and reasons for it. ________________________ Applicant's declaration 12. I enclose the Driving Certificate No. ______________________ Dated _____________________ Issued by____________________________________________. 13. I have submitted along with my application for learner's licence the written consent of parent/guardian Yes http://punjabtransport.nic.in/images/box3.jpg No http://punjabtransport.nic.in/images/box3.jpg 14. I have submitted along with the application for learner's licence/I enclose the medical fitness certificate Yes http://punjabtransport.nic.in/images/box3.jpg No http://punjabtransport.nic.in/images/box3.jpg 15. I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules 1989 Yes http://punjabtransport.nic.in/images/box3.jpg No http://punjabtransport.nic.in/images/box3.jpg 16. I am exempted from primary test under rule 11(2) of the Central Motor Vehicle Rules 1989 Yes http://punjabtransport.nic.in/images/box3.jpg No http://punjabtransport.nic.in/images/box3.jpg I hereby declare that to the best of my knowledge and belief the particulars given above are true. Yes http://punjabtransport.nic.in/images/box3.jpg No http://punjabtransport.nic.in/images/box3.jpg Note: Strike out whichever is inapplicable. ______________________ Signature/Thumb Impression of applicant CERTIFICATE OF TEST OF COMPETENCE The applicant has passed the test prescribed under rule 15 of the CMV rules; 1989.The test was conducted on vehicle with Reg.No.________________________on__________________. Result of the Test: Passed http://punjabtransport.nic.in/images/box3.jpg Failed http://punjabtransport.nic.in/images/box3.jpg Absent http://punjabtransport.nic.in/images/box3.jpg If failed Reasons for failure http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg http://punjabtransport.nic.in/images/box5.jpg Name of Testing Autority http://punjabtransport.nic.in/images/box5.jpg Code http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg http://punjabtransport.nic.in/images/box3.jpg ______________ Signature of the Testing Authority
