FORM - 4                                                    No.-ITA/V/9/9/98 Sl. No.

(See rule - 14 of MV Act-1983)

FORM OF APPLICATION FOR LICENCE TO DRIVE A MOTOR VEHICLE

To

            The Licensing Authority 

             Naharlagun, Arunachal Pradesh 

              I apply  for a licence to unable me to drive Vehicle of the following decription as paid                     employee/PRIVATE/Public Service vehicle/Goods Vehicle.

            

a).   Motor cycle/Scooter (Without Gear)                  

b).   Motor cycle/Scooter (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.                                                     

                        PARTICULARS TO BE FURNISHED BY THE APPLICANT

  1. Name in full (In block letter) 

  2. Father's /Mother's/Gurdian's Husband name

  3. Permament Address                                    

                                                                             

                                                                             

                                                                             

4.     Present Address                                           

                                                                             

                                                                             

5.   Temporary address/Official address                 

                    ( If any)                                             

                                                                             

6.  Date of birth                                                     

7.  Educational Qualification                                  

8.  Identification marks                                          

9.  Blood Group and (RH Factor)                          

10.  Have you previously held driving licence, if so, give details :


11. Particulars and date of every eviction which has been ordered to be endorsed on any licence held by the applicant.


12.  Have you been subjected to a driving test 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 to


13.  Have you been disqualified for obtaining a licence to drive ? if so for what reason : 

14.  I enclose three copies of my recent photograph of the size five centimeters into six centimeters ( where laminated card is used to photograph are required.)  

15.  Have you been disqualified for obtaining a licence drive? if so for what reason  

16.  I enclose the driving licence  No.     issued by the dated

17.  I enclose the driving certificate No. dated

18. I have submitted along with my application for learner's I enclose the medical fitness certificate.

19. I have submitted along with my application for learner's I enclose the medical fitness certificate.

20.  I am exempted from the medical test under rule 4 of the Central motor vehicle Rule - 1989.

21.  I am exempted from the medical test under rule 11(2) of the Central motor vehicle Rule-1989.

22.  I have paid the fee Rupeed      

        I hereby decalare the best of my knowledge and belief the the particulars given above are true.

NOTE :- Strike out whichever is inapplicable.

 

 

 

Signature/Thumb impression of Applicant

Date :-

Place :-

CERTIFIED OF TEST COMPETENCE TO DRIVE

1.  The applicant has passed the test precribed under rule 15 of the central motor vehicle Rules, 1989 the test was conducted on for Scooter/Motor Cycle/LMV/HMV/MMV/PSV :

2.  The applicant has failed in the test.

Date :-

Two specimen Signature of Applicant :-        1) 

                                                                    2) 

Strike out whichever is inapplicable,         

 

xx

 

                                             

                                                                             

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