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9/29/2015

APPLICATIONFORMFORLICENCETODRIVEAMOTORVEHICLE

APPLICATIONFORMFORLicenceTODRIVEAMOTORVEHICLE
FORM4(Seerule14)
To
TheLicencingAuthority,

IenclosedLearnersLicenceNo

Dt.

IssuedbyL.A

IherebyapplyforaLicenceauthorisingmetodrivethefollowingvehicles(Tickat
theappropriatebox)

A)
B)
C)
D)
E)
F)
G)

Motorcyclebelow50cc
Motorcycleabove50cc
LightMotorVehicle(includesCars&Jeeps)
TransportVehicle
RoadRoller
InvalidCarriage(incaseofphysicallyhandicappedapplicants)
AnyOtherCategory

(Specifythecategoryinthebox)

(PleasefillthefollowingparticularsinCAPITALLettersonly)

1.FULLNAME(LeaveoneSpacebetweenfirstandlastname)

2.Son/Daughter/Wifeof

3.SEX

MALE

4.ADDRESS

FEMALE
PERMANENT

TEMPORARY

DoorNo.

Village/town/city
Mandal
District
Pincode
5.DATEOFBIRTH

6.EDUCATIONALQUALIFICATION

7.IDENTIFICATIONMARKS

8.(Optional):BLOODGROUP&Rh
FACTOR
Disclaimer:Theapplicantissolelyresponsibleforanymedicalcomplicationsthatmayariseduetowrong
declarationoftheBloodgroup.
9.Particularsanddateofeveryconvictionwhichhasbeenorderedtobeendorsedon

anyLicenceheldbytheapplicant.
10.ParticularsofdisqualificationoftheapplicantfromobtainingaLicencetodrive,andreasonsforit.

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9/29/2015

APPLICATIONFORMFORLICENCETODRIVEAMOTORVEHICLE

Applicant'sdeclaration

12.IenclosetheDrivingCertificateNo.

Dated

Issuedby
13.
14.
15.
16.

Ihavesubmittedalongwithmyapplicationforlearner'sLicencethe
writtenconsentofparent/guardian
Ihavesubmittedalongwiththeapplicationforlearner'sLicence/I
enclosethemedicalfitnesscertificate
IamexemptedfromthemedicaltestunderRule6oftheCentralMotor
VehicleRules1989
Iamexemptedfromprimarytestunderrule11(2)oftheCentralMotor
VehicleRules1989
Iherebydeclarethattothebestofmyknowledgeandbeliefthe
particularsgivenabovearetrue.

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Note:Strikeoutwhicheverisinapplicable.

Signature/ThumbImpressionofapplicant.

CERTIFICATEOFTESTOFCOMPETENCE
Theapplicanthaspassedthetestprescribedunderrule15oftheCMVrules,1989.

ThetestwasconductedonvehiclewithReg.No.

on

Theapplicanthaspassedthetestprescribedunderrule15oftheCMVrules,1989.
ResultoftheTest:Absent

Passed

Failed

IffailedReasonsforfailure
NameofTestingAutority
Code
SignatureoftheTesting
Authority

Submit

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