| . | |
| I, Sri / Smt / Kumari | |
| Son/Wife/Daughter of |
| a. D.L.Number | b. Date of Issue |
| e. Class of vehicle | Motor cycle upto 50 cc | Motor Cycle above 50 cc | ||
| Authorised to drive | Light motor vechicle | Transport vehicle | ||
| Invalid carriage | Road Roller | |||
| Any other Category | (Specify the category in the box) |
| g. ADDRESS | PERMANENT | TEMPORARY |
| Door No. | ||
| Village/Town/City | ||
| Mandal | ||
| District | ||
| Pincode |
| Signature / Thumb impression of Applicant |