APPLICATION NUMBER : W/72835/2018

TABLE ID : 2 DATE : 12-12-2018

Form-8

APPLICATION FOR THE ADDITION OF A NEW CLASS OF VEHICLE TO A DRIVING LICENSE

[See Rule 17(1)]

To,
Affix Your
The Licensing Authority, Recent
ALA, KOLLAM Passport Size
Photo
License Details

T
License No : 2/7644/2010

EN
Name of the Applicant

TM
J A Y A M O H A N C
Name of the Guardian

R
J C H A N D R A N K U T T Y

A
I, hereby apply for the addition of the following class / classes of motor vehicle(s) to the attached Licence

EP
1. MOTOR CYCLE WITH GEAR
I enclose,
a) A Medical Certificate in Form 1
D
S
b) Application for Learner's Licence in Form 2
LE

c) Driving Licence in Form 7

d) I have Paid the fee of Rupees : 1260 /-
IC

Date ...................
H

Signature or thumb impression of applicant

VE

Cerificate of test of competence to drive

The applicant has passed/failed in the test specified in Rule 15 of the central Motor Vehicles Rules,1989.The test was
R

conducted on a ............................................................................ (here enter description of vehicle) on date ............................

TO
O

Signature of testing authority

M

Name and designation

LA
A
ER
K

IT Services: NIC Kerala

Page 1/7
 APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
[See Rule 3(a), 13]

LEARNER'S LICENCE
[Valid if and only if Signed by a Competent Authority ]

Licence No................................................................Date................................................

Name of the Applicant : JAYAMOHAN C

Affix Your
Name of the Guardian : J CHANDRANKUTTY Recent
Passport Size
Date of Birth : 05/11/1987

T
Photo
Blood Group-RH Factor :

EN
TM
Present Address Temporary Address / Official Address
VARSHA BHAVAN

R
THEVALLY.PO
KOLLAM-9

A
EP
Marks of Identification :
1: D
S
2:
LE

is licensed to drive throughout India as a learner subject to the provision of Rule 3 of the Central Motor Vehicles Rules, 1989 ,
IC

a motor vehicle of following description :

1. MOTOR CYCLE WITH GEAR
H

The holder of the licence has passed the medical test under Rule 5 and the preliminary test referred to in Rule 11(1) of the
VE

Central Motor Vehicles Rules, 1989.

R
TO

This licence is valid from...............................................................to.....................................................

O
M

* Strike out whichever is inapplicable Signature and Designation of the Licensing Authority
LA
A

Warning :-
ER

The attention of the holder of this licence is drawn to Rule 3 of Central Motor Vehicles Rules, 1989 which prohibits him from
driving any motor vehicles unless he has besides him a person duly licensed to drive the vehicle and in every case,the vehicle
K

carries 'L' plates both in the front and in the rear of the vehicle

IT Services: NIC Kerala

Page 2/7
 APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
Form -1
Application cum Declaration as to the Physical Fitness
See Rule 5(2)

Name of Applicant : JAYAMOHAN C

Son / Wife / Daughter of : J CHANDRANKUTTY
Date of Birth : 05/11/1987 Affix Your
Recent
Age as on date of application : 31 Passport Size
Identification Marks : Photo
1 :
2 :

T
EN
Present Address Temporary Address / Official Address
VARSHA BHAVAN

TM
THEVALLY.PO
KOLLAM-9

R
A
EP
DECLARATION
(a) Do you suffer from epilepsy or from sudden attacks of loss of consciousness or giddiness from any cause? YES / NO

D
S
(b) Are you able to distinguish with each eye (or if you have held a driving licence to drive a motor vehicle for a period
LE

of not less than five years and if you have lost the sight of one eye after the said period of five years and if the
application is for driving a light motor vehicle other than a transport vehicle fitted with an outside mirror on the YES / NO
IC

steering wheel side ) or with one eye,at a distance of 25 metres in good daylight (with glasses,if worn) a motor car
number plate?
H
VE

(c) Have you lost either hand or foot or are you suffering from any defect of muscular power of either arm or leg? YES / NO
R

(d) Can you readily distinguish the pigmentary colours,red & green? YES / NO
TO

(e) Do you suffer from night blindness? YES / NO

O

(f) Are you so deaf as to be unable to hear (and if the application is for driving a light motor vehicle,with or without
M

hearing aid) the ordinary sound signal? YES / NO

LA

(g) Do you suffer from any other disease or disability likely to cause your driving of a motor vehicle to be a source of
A

danger to the public ,if so,give details? YES / NO

ER

I hereby declare that to the best of my knowledge and belief,the particulars given above and the declaration made
K

there in are true

.............................................
Signature or thumb impression of applicant
NOTE:
1) An applicant who answers 'Yes' to any of the questions (a),(c),(e),(f) and (g) or 'No' to either of the questions (b) and (d) should
amplify his answers (with full particulars) and may be required to give further of information relating thereto
2) This declaration is to be submitted invariably with medical certificate in the formI-A

IT Services: NIC Kerala

Page 3/7
 APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
Form - 2
[See rule 10]
FORM OF APPLICATION FOR THE GRANT OR RENEWAL OF LEARNER'S LICENSE

To,
The Licensing Authority,
ALA, KOLLAM Affix Your
1. Full Name : JAYAMOHAN C Recent
2. Son/Wife/Daughter of : J CHANDRANKUTTY Passport Size
Photo

I hereby apply for a licence authorising me to drive as a learner,the following motor vehicle(s):-

T
EN
1. MOTOR CYCLE WITH GEAR
and Motor Vehicles to the following description :

TM
...............................Particulars to be furnished by the applicant...............................
3. Permanent Address(Proof to be Enclosed) 4. Temporary Address / Official Address(If any)

R
VARSHA BHAVAN

A
THEVALLY.PO

EP
KOLLAM-9

D
S
5. Date of Birth(Proof of Age to be enclosed) : 05/11/1987
LE

6. Educational qualification : Graduate

7. Identification Marks 1 :
IC

2 :
H
VE
R
TO
O
M
LA
A
ER
K

IT Services: NIC Kerala

Page 4/7
8. Blood group - RH factor: ............

9. I hold an effective driving licence to drive:

(a) Motor cycle/Light motor vehicle/Medium Passenger motor vehicle/ Medium goods vehicle with effect from .................

10. Particulars of any driving licence previously held by applicant. Whether it was cancelled and if so, for what reason?

11. Particulars of any driving licence previously held by applicant in respect of the description of vehicle to which the application.
has applied?

12. Have you been disqualified for holding or obtaining a driving licence or learner's licence ? If so,for what reasons?

T
13. I enclose 3 copies of my recent photographs(passport size).

EN
14. I enclose medical fitness certificate dated ................................. issued by (doctor) ............................................................

TM
15. I have submitted along with my earlier application for learner's licence / I enclose the written consent of parent / guardian.

R
( In the case of application being a minor)

A
16. I enclose driving certificate dated ............................................................ issued by ............................................................

EP
....................................................................................................................................(Name and address of driving school).

17. I have paid the fee of

D
S
LE

18. I am exempted from the medical test under rule 6 of Central Motor Vehicles Rules,1989.
IC

19. I am exempted from the preliminary test under rule 11(2) of Central Motor Vehicles Rules,1989.
H
VE

Signature or thumb impresssion of the applicant Specimen signature or thumb impression of

R

the applicant.
TO
O

.............................................. For Office Use ..............................................

M

The applicant is exempted from the Medical Test under rule 6 and the preliminary test under Central Motor Rule11(2) of the
LA

Vehicles Rules 1989.

A

Learner's Licence may be issued

ER

The applicant was tested with reference to Rule11(1) of the Central Motor Vehicles Rules 1989
He has passed Learner's Licence may be issued
K

He has failed in the test, (Reason should be specified)

Learner's Licence may be refused

Signature of Licensing Authority or

other person authorised in this behalf

IT Services: NIC Kerala

Page 5/7
 APPLICATION NUMBER : W/72835/2018
TABLE ID : 2 DATE : 12-12-2018
CERTIFICATE FOR VISUAL STANDARDS FOR DRIVING

( To be filled in by Registered Ophthalmology )

Name of Applicant : JAYAMOHAN C

Son / Wife / Daughter of : J CHANDRANKUTTY
Date of Birth : 05/11/1987 Affix Your
Recent
Age as on date of application : 31 Passport Size
Identification Marks : Photo
1:
2:

T
EN
I have examined Shri/Smt. JAYAMOHAN C aged 31 and his/her visual standards are as follows:

TM
I. Visual Acuity
A B Sph Cyl Axis C

R
Visual Acuity Unaided Corrected Binocular

A
Corrected

EP
RE

LE
D
S
LE

II. Night blindness ............................................

IC

III. Squint............................................................
H
VE

IV.Field(Degree) Horizontal............................................Vertical............................................

V.Fundus:......................................................... RE ...........................................................LE
R
TO

Any other significant ocular morbidity .................................................................................

O

Candidate is Fit/Unfit to drive a Category l / ll vehicle .........................................................

M

Unfit due to criteria .......................................... mentioned above .......................................

LA

(Category-I means Non Transport Vehicles which include Motor Cycles, Motor Cars, etc.specified as such in Central Goverment
A

Notification No.S.O.1248(E) dated 5th November 2004 as non-transport vehicles)

ER

(Category-II means Transport vehicles which include Autorickshaws, Taxis, Stage Carriages, contract Carriages, goods carriages,
K

Private Service Vehicles etc. specified as such in the said Notification.)

Signature of candidate: Signature of Ophthalmologist

Place : Seal
Date : 12-12-2018

IT Services: NIC Kerala

Page 6/7
Certificate to be issued by an Ophthalmologist with a registered post graduate qualification in Ophthalmology.
The seal should contain the name, qualifications and register number of the Ophthalmologist.

Visual Standards criteria for driving

Category I: Non-Transport Vehicles- includes Motor Cycles (MC), Owner driven Light Motor Vehicles (LMV)
(Vehicles not fitting criteria for category ll)
Category II: Transport Vehicles- Heavy Motor Vehicles (HMV), Commercial Passenger carrying vehicles, Goods carriers
(Any Category requiring issuance of a Badge)

I. Visual Acuity
1A. Unaided

T
Category I: Binocular unaided visual acuity of 3/60 or better

EN
1B. Corrected

TM
Category I : Worse eye corrected visual acuity of 6/60 or better
Category II: Worse eye corrected visual acuity of 6/12 or better

R
1C. Binocular Corrected

A
Category I: Binocularly, with glass correction, the candidate should be able to read 6/12 or better.

EP
Category II: Binocularly, with glass correction, the candidate should be able to read 6/9 or better.

II. Night blindness *

D
S
Presence of night blindness is not acceptable for both category II and I
LE

*This being a symptom is recorded as reported by the patient.

IC

III. Manifest Squint

Category I: Squint with visual acuity as in criteria I acceptable.
H

Category II: Any squint is unacceptable for Category II

VE

IV. Field
R

Binocular field checked by confrontation methos

TO

Category I: Horizontal field of vision of 120 degrees and vertical of 40 degrees

Category II: Horizontal field of vision of 180 degrees and vertical of 40 degrees
O
M

V. Fundus
Undialted fundus examination unless otherwise indicated.To be recorded as WNL(Within noramal Limits) or any specific
LA

pathology noted.
Any Pathology that can affect night vision, field, acuity should be investigated and the clination should decide on fitness.
A

Colour vision problems by itself are not impediment to driving.

ER
K

IT Services: NIC Kerala

Page 7/7