FORM 4 [ See Rule 14 ] FORM OF APPLICATION FOR LICENCE TO DRIVE A MOTOR VEHICLE To The Licensing Authority, Spce for 1[passport sizephotograph] I apply for a licence to enable me to drive vehicles of the following description : (a) Motor cycle 2[without gear] (b) Motor cycle with gear (c) Invalid carriage (d) Light motor vehicle (e) 2[Medium goods vehicle] (f) Medium passenger motor vehicle 3[(g) Heavy goods vehicle (h) Heavy passenger motor vehicle] (i) Road roller (j) Motor vehicles of the following description : PARTICULARS TO BE FURNISHED BY 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 marks (1) 1[8 Optional Blood grouup Rh factor (2) 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 reason? 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 Downloaded from www barrackpore gov in, the official website of Barrackpore Sub-Division Date of test Testing authority Result of test 1 2 3 4 13 I enclose three copies of my recent 1[passport size photograph] (where laminated card is used no photographs are required) 14 I enclosed the learner's licence 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 licence the written consent of parent/ guardian 17 I have submitted along with the application for learner's licence/I enclose the medical fitness certificate 18 I am exempted from preliminary test under Rule 6 of the Central Motor Vehicles Rule, 1989 19 I am exempted from preliminary test under Rule 11 (2) of the Central Motor Vehicles Rles, 1989 20 I have paid the fee of Rs I hereby declare that to the best of my knowledge nd belief the particulars given above are true * Strike out whichever is inapplicable Dated 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 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 lised out) Date : Signature of Testing Authority Full name and designation Two specimen signatures of Applicant : 1 2 * Strike out whichever is inapplicable Downloaded from www barrackpore gov in, the official website of Barrackpore Sub-Division
