Form of application for the issue of Learner's License FORM - 2 { See Rule 10 } To The Licensing Authority I hereby apply for a license authorizing me to drive as learners, the following motor vehicles:- a) b) c) d) e) f) g) h) Motor Cycle without gear Motor cycle with gear Light Motor Vehicle Medium goods vehicle Medium Passenger vehicle Heavy goods vehicle Heavy passenger vehicle Excavator/Bull Dozer/road roller Particulars to be furnished by Applicant 1) 2) 3) 4) Full Name Permanent address (proof to be enclosed) (proof to be enclosed) Date of birth with proof5) Son/ Wife/ Daughter of Temporary address/ Official address Educational Qualification Identification marks Blood group 6) 7) 8) Published on National Portal of India (india.gov.in) 9) I hold an effective license to drive Motor cycle Medium passenger vehicle Light motor vehicle Medium goods vehicle 10) with effect from Particulars of any driving license previously held by applicant if any 11) Particulars of any learners license Previously held by applicant in respect of the description of vehicle to which The applicant has applied. 12) Have you been disqualified for holding or obtaining driving license or learners license? If so what reasons. 13) I enclosed medical fitness certificate dated issued by (doctor) 14) I have submitted along with my earlier application for learners license/ I enclosed the written consent of (in case of applicant being minor) 15) I enclosed driving certificate dated issued by (Name & address of the driving school) 16) I have paid the fees of Rs. Yes No Yes No Yes No Yes No parent/ guardian /- {Signature or Thumb impression Published on National Portal of India (india.gov.in) of the applicant} FORMS [See rule 2 (e)] [FORM 1] [See rule 5 (2)] APPLICATION CUM DECLARATION AS TO PHYSICAL FITNESS Name of the applicant Permanent address Temporary address Official address (if any) Identification marks . (1) (2) Son/ wife/ daughter of (a) Date of birth (b) Age on date of application No Yes l. 4. 5. 6. 2. 3. Published on National Portal of India (india.gov.in) (c) I have you lost either hand or foot or are Can you readily distinguish the pigmentary(d) Do you suffer from night blindness?(e) Are you so deaf so as to be unable to hear (f) Do you suffer from any other disease or (g) (b) Are you able to distinguish with each eye (or if you have held a driving license to drive a motor vehicle for a period 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 steering wheel side) or (with one eye, at a distance of 25 meters in good day light with glasses, if worn) a motor car number plate? you suffering from any defect of muscular power of either arm or leg? colour, red or green? (and if the application is for driving a light motor vehicle, with or without hearing disability likely to cause your driving of a motor vehicle to be a source or danger to the public, if so, give details? Yes No aid) the ordinary sound signal? Yes No No Yes Yes No No Yes No Yes I hereby declare that, to the best of my knowledge and belief, the particulars given above and the declaration made therein are true. (Signature or thumb-impression of the applicant) Notes:- (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 information relating thereto. Published on National Portal of India (india.gov.in) Declaration (a) Do you suffer from epilepsy, or from Yes No sudden attacks of loss of consciousness of giddiness from any cause? (2) This declaration is to be submitted invariably with medical certificate in form 1- (a). FORM 1-A [See Rules 5 (1), (3), 710 (a), 14 (d) and 18 (d)] MEDICAL CERTIFICATE (To be filled in by a registered medical practitioner appointed for the purpose by the State Government or person authorizes in this behalf by the State Government referred to under sub-section (3) of section 8) Name of the applicantl. 2. Identification marks . (1) (2) 3. (a) (c) (d) (e) (f) (g) (b) Does the applicant, to the best of your judgement, suffer from any defect of vision? If so, has it been corrected by suitable spectacles? Can the applicant, to the best of your judgement, readily distinguish the pigmentary colours, red and green? In your opinion, is he able to distinguish with his eye sight at a distance of 25 meters in good day light a motor car number plate? In your opinion, does the applicant suffer from a degree of deafness which would prevent his hearing the ordinary sound signals? In your opinion, does the applicant suffer from night blindness Has the applicant any defect of deformity or loss of member which would interfere with the efficient performance of his duties as a driver? If so, give your reasons in details. Optional Blood group of the applicant (if the RH factor of the applicant (if the applicant (a) applicant so desires that the information may be noted in his driving license) (b) so desires that the information may be noted in his driving license) Yes No Yes No No Yes Yes No Yes No Yes No Published on National Portal of India (india.gov.in) Declaration made by the applicant in Form 1 as to his physical fitness is attached. Certificate of Medical Fitness Certify that :- (i) (ii) (iii) (iv) I have personally examined the applicant That while examining the applicant I have directed special attention to his/her distance vision. While examining the applicant, I have directed special attention to his/her hearing ability, the condition of the arms, legs, hands and joints of both extremities of the applicant and; I have personally examined the applicant for reaction time, side vision and glare recovery, (applicable in ease of persons applying for a license to drive goods carriage carrying goods of dangerous or hazardous nature to human life). And, therefore, I certify that, to the best of my judgement, he/she is medically fit/not fit to hold a driving license. The applicant is not medically fit to hold a license for the following reasons: Signature 1.Name and designation of the Medical Officer/Practitioner (Seal) Date Published on National Portal of India (india.gov.in) 2. Registration number of medical officer Signature or thumb-impression of the candidate Shri/ Smti/ Kum
