FORM - 4 (See Rule 14) Form of application for license to drive a Motor Vehicle passport size photograph To The Licensing Authority ...................................... I apply for a license to enable me to drive vehicles of the following description: a) Motor Cycle without gear b) Motor Cycle with gear c) Invalid carriage d) Light Motor Vehicle e) Medium goods Vehicle f) Medium passenger motor vehicle g) Heavy goods vehicle h) Heavy passenger motor vehicle i) Road Roller j) Motor vehicle of the following description PARTICULARS TO BE FURNISHED BY THE APPLICANT 1. Name : ......................................................... 2. Son / Wife / Daughter of : ......................................................... 3. Permanent address : ......................................................... (Proof to be enclosed) .......................................................... 4. Temporary address/Official address : ......................................................... any) 5. Date of Birth (Proof to be enclosed : ......................................................... 6. Educational Qualification. : ......................................................... 7. Identification Marks. : (1)........................................................................ (2)........................................................................ 8. Optional: Blood Group/RH Factor : 9. Have you previously held driving ......................................................... License? If so, give details. 10. Particulars and date of every conviction which has been ordered to be endorsed on .......................................................... any license held by the applicant. : 11. Have you been disqualified for obtaining a license to drive? If so, for what ......................................................... reason? : 12. Have you been subject to a driving test as to your fitness or ability to drive a vehicle ......................................................... in respect of which a license to drive is applied for? If so give the following details : Date of test Testing authority Result of test 1 2 3 4 13. I enclose three copies of my recent Passport size photograph (where laminated card is used no photographs are required) 14. I enclose the learner' s license No......................... dated . . . . . . . . .. issued by Licensing Authority. 15. I enclose the Driving Certificate No. . . . . dated. . . ..issued by. . . . . . 16. I have submitted along with my application for Learner's License the written consent of parent/ guardian. 17. I have submitted along with my application for Learner's License/I enclose the medical fitness certificate. 18. I am exempted from the medical test under rule 6 of the Central Motor Vehicles Rules 1989. 19. I am exempted form preliminary test under rule 11 (2) of the Central Motor Vehicle Rules 1989. 20. I have paid the fee of Rs..................................................... I hereby declare that to the best of my knowledge and belief the particulars given above are true NOTE: Strike out whichever is inapplicable Date ................................. Signature /Thumb impression of Applicant CERTIFICATE OF TEST OF COMPETENCE TO DRIVE The applicant has passed the test prescribed under rule 15 of the Central Motor Vehicle Rules, 1989. The test was conducted on . . . . . . . . . . . . . . . . . . . . . . ...................... . . . . . (here enter the registration mark and description of the vehicle). . . . . .. . . . . . . .on (date)................... The applicant has failed in test (The details of the deficiency to be listed out) ...................................... ...................................... ............................................. Date: Signature of Testing Authority Two Specimen Signature of Applicant: Full Name and Designation. 1. 2. * Strike out whichever is inapplicable
