GUYANA ,REVENUE AUTHORITY

A p p l i c at i o n 1 Ren ew al f o r Dr i v er s ' , Pr o v i s i o n al & Co n d u c t o r s ' L i c en c e

Last Name First Name Middle Int.
- IL- - _
Address
I~ 'I
1'-----
Sex
DMwF
I
1_-
Colour of eyes
ID Type
oNational Identification
10 Number
oPassport oOther, please specify. _
TIN
1__ - 1__ -
0,New Licence lu\ ' I Renewal I\ i l Driver Licence oprovisional Licence oConductor Licence
oCar 0Van 0Cycle 0Mini Bus 0Hire Car o Motor Bus 0Tractor 0Lorry
Date ofTest which test was made
Result ofTest , 0
Pass Fail
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The Applicant is required to furnish answers to t~e following questions by sel~cting "Yes" or "No" 'Opposite each question. Yes
1. Do you suffer from Epilepsy, sudden attacks 9f disabilitY, giddiness or fainting? 0
2. Are you able to read from a distance pf 25 yds in good daylight (with glasses, if worn) a Motor Vehicle 0
number plate containing six (6) letters and figures? ,
3. Have you lost either hand or foot, or are you suffering from any defect in movemen~control, ' 0
or muscular power of either arm or leg?
if yes, give particulars.
No
o
o
o
I ~- - - - - - - - - - - - - - - - - - - - -
Ideclare that Iam not suffering from any.other disease or disability, which would be likely to cause the driving by me of a motor vehicle to be
a scurce of danger to ttie public. . ,'. :
Ifurther declare thaI to the best of my information and particulars given in the declarations on this application hereof are true. .
Ifurther declare that it is an offen'ce for a person to use a motor vehicle on public road unless there is in fore!! a p!llicy on the insurance or
.a s~curity against third party risks covering. the use by that person of that vehicle.
Si nature
Date
Appiicarit'who answer~"yes" to question 3 in declaration of Physical fitness 'may either (1).claim to be subjected to a driving test,
(11) si~," the E Declar~tion, overleaf, if in the position to do so. .
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MotorVehicles & Road Traffic Regulations
GUYANA REVENUE AUTHORI TY
A p p l i c at i o n I Ren ew al f o r Dr i v er s ' , Pr o v i s i o n al & Co n d u c t o r s ' L i c en c e
I c l ai m t o b e s u b j ec t t o a t es t t o m y f i t n es s o r ab i l i t y t o d r i v e a m o t o r v eh i c l e o f t h e c l as s o r c l as s es s p ec i f i ed i n t h i s ap p l i c at i o n .
1 / ' I .
Si n at u r e -! Dat e
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. I hereby declare that a drivers' certificate under the Motor Vehicles' ordinance, 1935 Drivers' Licence under the Motor Vehicle and Road Traffic
Ordinance, was issued to me on the - - - - - - bythe - - - - r- - - certifying authority to drive a motor vehicle of the type
in respect of which a drivers' licence is now applied for by me and the date my last application for a drivers' certificate the disease or physical
disability from which I am suffering has not become more acute and that I am not suffering from any disease or disability !19t disclosed on such
last application.
Dat e
,
Cl as s o f L i c en c e
Ex p i r at i o n Dat e
1 -
/
L i c en c e Co v er Nu m b er
1'--- -
L i c en c e Nu m b er
Cer t i f i c at e o f Co m p et en c e Nu m b er
Dat e I s s u ed
Fo r ei g n L i c en c e Nu m b er Co u n t r y
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Ex p i r at i o n Dat e ,
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Mo t o r Veh i c l es & Ro ad Tr af f i c Reg u l at i o n s .