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 authorising me to drive the following vehicles ( Tick at the appropriate box)

A) Motor cycle below 50cc

B) Motor cycle above 50cc

C) Light Motor Vehicle (includes Cars & Jeeps)

D) Transport Vehicle

E) Road Roller

F) Invalid Carriage (incase of physically handicapped applicants)

G) Any Other Category (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)


2. Son/Daughter/Wife of


3. SEX MALE     FEMALE

4. ADDRESS PERMANENT TEMPORARY

    Door No.

    Village/town/city

    Mandal

    District

    Pincode

5. DATE OF BIRTH     DD     MM     YYYY

6. EDUCATIONAL QUALIFICATION

7.IDENTIFICATION MARKS 1

2

8. (Optional) : BLOOD GROUP & Rh FACTOR

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 licence held by the applicant.

10. Particulars of disqualification of the applicant from obtaining a licence 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    No

14. I have submitted along with the application for learner's licence/I enclose the medical fitness certificate Yes    No

15. I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules 1989 Yes    No

16. I am exempted from primary test under rule 11(2) of the Central Motor Vehicle Rules 1989 Yes    No

I hereby declare that to the best of my knowledge and belief the particulars given above are true. Yes    No

Note:Strike out whichever is inapplicable.

______________________
Signature/Thumb Impression
of applicant

CERTIFICATE OF TEST OF COMPETENCE

The test was conducted on vehicle with Reg.No.________________________on__________________.
The applicant has passed the test prescribed under rule 15 of the CMV rules, 1989.

Result of the Test: Passed    Failed    Absent

If failed Reasons for failure

Name of Testing Autority

Code

___________________
Signature of the Testing
Authority

A)		Motor cycle below 50cc
B)		Motor cycle above 50cc
C)		Light Motor Vehicle (includes Cars & Jeeps)
D)		Transport Vehicle
E)		Road Roller
F)		Invalid Carriage (incase of physically handicapped applicants)
G)		Any Other Category (Specify the category in the box)

3. SEX	MALE	FEMALE
4. ADDRESS	PERMANENT	TEMPORARY
Door No.
Village/town/city
Mandal
District
Pincode

6. EDUCATIONAL QUALIFICATION
7.IDENTIFICATION MARKS	1
	2
8. (Optional) : BLOOD GROUP & Rh FACTOR

13.	I have submitted along with my application for learner's licence the written consent of parent/guardian	Yes	No
14.	I have submitted along with the application for learner's licence/I enclose the medical fitness certificate	Yes	No
15.	I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules 1989	Yes	No
16.	I am exempted from primary test under rule 11(2) of the Central Motor Vehicle Rules 1989	Yes	No
	I hereby declare that to the best of my knowledge and belief the particulars given above are true.	Yes	No

If failed Reasons for failure


Name of Testing Autority
Code
	___________________ Signature of the Testing Authority