FORM 4 (See rule 14 (1)) FORM OF APPLICANT FOR LICENCE TO DRIVE A MOTOR VEHICLE To The Licensing Authority ................ ................ 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, namely ........... PARTICULARS TO BE FURNISHED BY APPLICANT 1. Full Name ................................................ 2. Son/Wife/daughter of ........................... 3. Permanent address .......................... (Electoral Roll/ Life Insurance Policy/Passport/Pay slip issued by any office of the Central Government/State Government or a local body/any other document or documents as may be prescribed by the State Government6 /Affidavit sworn before an Executive Magistrate or a First Class Judicial Magistrate or a Notary Public to be enclosed). 4. Temporary address/Official address. If any .................. 5. Duration of stay at the present address .................... 6. Date of Birth ................................. (Birth certificate/school certificate/affidavit sworn before an Executive Magistrate or a First Class judicial Magistrate or a Notary Public to be enclosed) 7. Place of birth ............................... 8. If place of birth outside India, when migrated to India .............. 9. Educational Qualification ......................... 10. Identification mark (s) 1 ............... 2 ............... 11. Declaration of citizenship status ........................ (i) If deemed Citizen or Citizen by birth .................. (Birth certificate and school certificate in support of Citizenship as Indian to be enclosed) (ii) If Citizenship is acquired by Descent/Registration............. (In case citizenship acquired by Descent, Birth certificate, land/property document of parent /in case of citizenship acquired by registration, certificates to be enclosed) (iii) If citizenship by Naturalization ................................. (Certificate of Naturalization and Certificate of Registration to be enclosed) (iv) If non Indian Citizen (Valid passport or other travel document and such other document or authority as may be prescribed by law to be enclosed) 12. Blood group .............................................. (RH (Rhesus) factor .......................................... 13. Have you previously held driving licence? If so, give details ........................... 14. Particulars and date of every conviction which has been ordered to be endorsed on any licence held by the applicant.... ................................................... . 15. Have you been disqualified for obtaining a licence to drive? If so, what reasons ................... .................................................. 16. Have you been subject 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:- Date of test Testing authority Result of test 1. 2. 3. 4. 17. I enclose three copies of my recent passport size photograph (where laminated card is used no photographs are required). 18. I enclose the learner's licence No ....... Dated .............issued by the licensing authority. 19. I enclose the driving certificate No .......dated ........... issued by .......... . 20. I have submitted along with my application for learner's licence the written consent of parent/guardian. 21. I have submitted along with the application for learner's licence/I enclosed the medical fitness certificate. 22. I am exempted from the medical test under rule 6 of the Central Motor Vehicles Rules, 1989. 23. I am exempted from preliminary test under rule 11(12) of the Central Motor Vehicles Rules, 1989. 24. I have paid the fee of Rs ................... "Strike out whichever is inapplicable. Dated ........... Signature/Thumb impression CERTIFICATE OF TEST OF COMPTENENCE TO DRIVE The application 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 Twp specimen signature of applicant: 1. ............... 2. ................ Strike whichever is in applicable. Note: -The application along with the scanned copies of the required documents may also be sent to the concerned Licensing Authority through Electronic Mall, if allowed by the concerned State Government/ Union Territory Administration. In such cases, the licensing Authority shall scrutining the application and intimates the applicant about the acceptance/ any discrepancy. In case the application is accepted, the applicant shall be intimated through Electronic Mail to report the Authority concerned and on an appointed date along with the documents for further verification, submission of application fee and examination of the applicant.
