F O R M 4 FORM OF APPLICATION FOR LICENCE TO DRIVE A MOTOR VEHICLE TO The Licensing Authority: Space for passport photograph I apply for a licence 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) Transport Vehicle (f) Road Roller (g) 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 (if any) 5. Date of Birth :: (proof to be enclosed) 6. Educational qualification :: 7. Identification mark(s) :: 1) 2) 8. Optional - Blood group - RH factor :: 9. Have you previously held driving licence :: if so, give details. 10, Particulars and date of every conviction :: which has been ordered to be endorsed on any licence held by the applicant. 11. Have you been disqualified for obtaining :: a licence to drive? If so, for what reasons. 12. Have you been subjected to a driving :: test as to your fitness or ability to drive a vehicle in respect of which a licence to drive is applied for? If so, give the following details: 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 Licence No.......... dated.......issued by Licensing Authority:: 15. I enclose the Driving Certificated No........ dated........ issued by:: 16. I have submitted alongwith my application for Learner's Licence the written consent of parent/guardian 17. I have submitted alongwith the application for Learner's Licence/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 from preliminary test under Rule 11(2) of the Central Motor Vehicles Rules, 1989, 20. I have paid the fee of Rs........challan No........dt........ Sl.No. DATE OF TEST TESTING AUTHORITY RESULT OF TEST 1 2 3 4 NOTE: Strike out whichever is inapplicable. Dated: Signature / Thumb impression of applicant 1. CERTIFICATE OF TEST OF COMPETENCE TO DRIVE The applicant has passed the test prescribed under Rule 15 of the Central Motor Vehicles Rules, 1989. The test was conducted on ......... (here enter the registration mark and description of the vehicle) :.........On (date) ........... The applicant has failed in the test. (The details of the deficiency to be listed out) Date: Signature of Testing Authority Full name and designation Two specimen signatures of applicant: 1) 2) *strike out whichever is inapplicable.
