APPLICATION FORM FOR THE GRANT OR RENEWAL OF LEARNER'S Licence

FORM-2(See rule - 10)
To
The Licencing Authority,


.
I hereby apply for a Licence authorising me to drive as a learner for the following motor vehicles
(Tick in the appropriate box)
  1. Motor cycle below 50cc
  2. Motor cycle above 50cc
  3. Light Motor Vehicle (includes Cars & Jeeps)
  4. Transport Vehicle
  5. Road Roller
  6. Invalid carriage (incase of physically handicapped applicants)
  7. Any other category (Specify the category in the box)

(Please fill the following particulars in CAPITAL Letters only)
  1. FULL NAME(Leave one space between first and last name)
  2. Son/Daughter/Wife of
  3. SEX MALE FEMALE    
  4. ADDRESS PERMANENT TEMPORARY
    Door No.
    Village/town/city
    Mandal
    District
    Pincode
  5. DATE OF BIRTH
  6. EDUCATIONAL QUALIFICATION
  7. IDENTIFICATION MARKS

  8. (Optional) : BLOOD GROUP & Rh FACTOR
    Disclaimer : The applicant is solely responsible for any medical complications that may arise due to wrong declaration of the Blood group.
  9. Effective driving Licence to drive the following class of vehicles held by the applicant.(Tick inthe appropriate box).
    A   B   C   D   E   F   G  
    Name of Licencing Authority Licence Number Valid upto
  10. Particulars of any driving Licence previously held by applicant. Whether it was cancelled and if so, for what reason.

  11. Particulars of any learners Licence previously held by applicant in respect of the description of vehicles to which the applicant has applied.

  12. Have you been disqualified for holding or obtaining Licence or learners Licence? If so, for what reasons.



    Applicant's Declaration

  13. I enclose medical fitness certificate dated:
    Issued by doctor:
  14. I have submitted along with my earlier application for learner's Licence / I enclose the written consent of Parent / Guardian (In the case of applicant being a Minor)
  15. I enclose driving cerificate dated Issued by
  16. I have paid the fee of Rs.
  17. I am exempted from the medical test under rule 6 of Central Motor Vehicle rules 1989.
  18. I am exempted from the preliminary test under rule 11(2) of Central Motor Vehicle rules 1989.
    DATE : 
    *Strike out whichever is inapplicable   Specimen Signature of Applicant
Declaration under sub-section(2) of section 7 of the Motor Vehicle Act, 1988
(By the guardian in the case of applicants who is a minor)
Sri/Kumari:
Son/Daughter :
who is a minor under my care and i accept responsibility for his/her driving. If ar a later date I decide not to
accept responsibility for his/her driving. I shall intimate the Licencing Authority in writing for the cancellation
of the Licence. I give my consent for his/her obtaining lerarners Licence.

Name and full address of
Parent/Guardian
Relationship
Signature of the parent/Guardian

   (To be signed in the presence of the Licencing Authority or person authorised in this behalf by Licencing Authority)

FOR OFFICE USE:
EXEMPTED from test under rule 6 & under rule 11(2) of CMV rules YES NO

TEST under rule 11(1) of CMV rules
Result : PASSAD FAILED ABSENT

Decision ISSUE REFUSE


Reasons of Refusal:
DATE
Signature of Licencing Authority
CODE