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Application Number Form of Application for New Licence to Drive a Motor Vehicle (Read the instructions on page-5 carefully before filling the form) To, The Licensing Authority State * Name of the RTO/DTO UID
586594 *
LL DL
GJ-Gujarat
GJ05 -RTO,SURAT
Part A
First Name 1. Name of the applicant Gender
Middle Name
Last Name
ROHIDAS
Male
13-12-1990
S
Female Others or 1.2 Age(In Years) 22
LONARI
VARNGAV
2(a) If place of birth is out side India, Month & Year when migrated to India: Month 3 .Country by Birth 3(a) Email Address 4. Name of Year
IND-INDIA
NITESH_MAHAJAN@ROCKETMAIL.COM
Father First Name* Mother Husband Guardian Middle Name Last Name
SAMPAT
5. Permanent address :(Proof to be enclosed)
LONARI
6. Present Address Present Address is same as Permanent Address
a) Flat Number b) Flat / House Name c) House Number/Plot No 22 d) Street e) Locality f) Village / Town / City g) Taluka / Mandal h) District i) State j) PIN code * k) Phone l) Mobile
SANJAYNAGAR LIMBAYAT
UDHNA YARD
CHOURYASI SURAT
GJ-Gujarat
394210
8140318831
Years Months Registration Descent Naturalization Years Non Indian Months
* *
Birth
2-Below 8th
A+
Part B
11*Requested Transaction Service (with class of vehicle) S.No. DESCRIPTION OF VEHICLE TYPE
Application Number
586594
New DL
New LL
1
2
3
4 5
6 7
9
10 11
12 13
14 15
16 17 18
19
Part C
12) List of Enclosures (for Age Proof, Address Proof etc.,) Document Type
A-Age Proof
Issuing Authority/Institute
GOVERMENT
E-Educational Certificate
1229
NAGAR PRATHMIK
27-02-2005
Part - D
13) I have submitted along with my application for Learners Licence the written consent of my parent/guardian: - (For Candidates having age below 18 years) 14) I have submitted along with my application for Learners Licence , I enclosed all the Necessary Enclosures / Certificates: 15) I am exempted from the Medical test under rule 6 of the Central Motor Vehicles Rules, 1989 :16) I am exempted from preliminary test under rule 11(2) of the Central Motor Vehicles Rules, 1989 :17) I have been convicted / disqualified / my Licence was cancelled /suspended / my Licence was revoked Yes No
No No No No
586594
I hereby declare that to the best of my knowledge and belief the particulars given above are true and I have enclosed all the necessary documents required as per the rules.
Date 8-4-2013
Part - E
UNDER SECTION 7(2) OF THE MOTOR VEHICLES ACT, 1988 Shri / Kumari son/daughter of
...................................................................... ......................................................................
who is a minor is under my care and I accept forhis/her driving .
If at a later date I decide not to accept responsibility for his/her driving I shall intimate the licensing authority in writing for the cancellation of the licence. I give my consent for his/her obtaining learners licence.
Name and full address of the parent/guardian Name of the Guardian Address City District Pincode Relationship : : : : : :
Signature of Parent/Guardian
(To be signed in the presence of the licensing authority or person authorized in this behalf by the licensing authority)
Part - F
FOR OFFICE USE 1) The applicant is exempted from the medical test under r. 6 and the preliminary test under r. 11(2) of the Central Motor Vehicles Rules, 1989. Learners licence may be issued 2) The applicant was tested with reference to r. 11(1) of the Central Motor Vehicles Rules, 1989. He has passed the test. Learners licence may be issued 3) He / She has failed in
............. .............
4) Registration Mark(s) of the vehicle(s) on which Driving Skill test was conducted S.No. Class of Vehicle Registration Mark of the vehicle Details of Skill Test
Result
Application Number
586594 .............
5) Learners licence may be refused. 6) Signature of licensing authority or other person authorized in this behalf. *Strike out whichever is inapplicable.
Submit
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Instructions for filling up theUnified Application Form for New Learner Licence / Driving Licence
1. 2. 3. 4. 5. 6. This form can be used for applying for New Learners Licence (LL) or Driving Licence (DL). Please fill up the data in Boxes with CAPITAL letters only. Columns marked as ( *) are mandatory. Enclosures: The Applicant should produce the proof for claims made in the Application where ever necessary. A set of codes defined for each of such type of enclosures is shown in HELP section ( See Code List -A,B,C). The Licensing Authority Code or RTO Code: The RTO/DTO office under whose jurisdiction the applicant resides or his/her place of business. Name of the Applicant : Fill the Applicant's name in the order of first name, middle name and surname/family name. However ensure that the name is entered as per the relevant records being produced as proof. Eg. JANGA REDDY CHEBANDI, DEVSINGH NAIK, SULTAN ISMAIL MOHAMMED Class or type of Vehicle(COV): Different class of vehicles are given in column 1 1. at least one class / type of vehicle should be selected to fill the unified application form. Part -A: If you are not holding an LL/DL please fill in all relevant columns i.e. 1 -9 of Part-A Part-B: It is mandatory to specify the class of v ehicles for which the LL/DL is to be issued from column 1 1 (Required Transaction Services) by putting tick ( ) mark. reference Part-C: It is mandatory to fill column 1 2 to provide details on the required documents like age proof, qualification proof etc. The number of the document enclosed also should be written as proof. If you are holding a DL or LL , please mention those details also in these columns. Part-D: The applicant shall fill this part wherever applicable. Part-E: If the Applicant is minor, this form can be filled by her/his parents and the licensing authority shall mention in the endorsement. Part-F: For Office Use only.
7. 8. 9. 10.
Glossary
RTO - Regional Transport Office DL - Driving Licence PSV - Public Service Vehicle DTO - District Transport Office COV - Class/Type of Vehicle LL - Learners Licence
HELP for Unified Application Form for Licence to Drive Motor Vehicle
CODE LIST A (TYPE OF ENCLOSURES SUPPORTING THE CLAIM MADE IN THE APPLICATION) TYPE DESCRIPTION TYPE DESCRIPTION
A B C D E F H I Age Proof Psv Badge First Aid Certificate Driving Licence (DL) Educational Certificate FIR(First Information Report) Hill Driving Training Certificate International Driving Permit (IDP) L M N P T V X Z Learners Licence (LL) Medical Fitness Ration Card Passport Driving Training Certificate Visa Military Licence Hazardous Training Certificate
S.No
39 50 51 52 53 54 55 56 57 58 59 70 80 81 82 90 91
DESCRIPTION
Any Other Graduation Not specified above MA / MBA / M.Com / M.SC Post Graduate Diploma In Science / Arts / Commerce / Management Post Graduate Diploma In Engineering / Medicine M Sc (Agriculture / Vet. Sciences) M E ( other than Mechanical ) M E (Mechanical) MS / MD / MHMS / MAMS / MDS Master of Education / Law CA / ICWA / ICS or equivalent Any Other Post Graduation / PG Diploma Not specified above M Phil. ( Sciences / Arts / Commerce/ Education / Law / Management / other faculties) Ph.D. ( Sciences / Arts / Commerce/ Education / Law / Management / other faculties) Ph.D in Engineering Ph. D. in Medicine M. Ch. ( Surgery )/ D.M. ( Medicine ) D. SC. ( Sciences / Arts / Commerce / Education / Law / Management / other faculties)
CODE LIST
CODE
AP AR AS BR CG DL GA GJ HR HP JK JH
STATE NAME
Andhra Pradesh Arunachal Pradesh Assam Bihar Chattisgarh Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand
CODE
KA KL MP MH MN ML MZ NL OR PY PB RJ
Kerala
STATE NAME
Karnataka
CODE
SK TN TR UP UA WB CH AN DN DD LD
Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal
STATE/ UT NAME
Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan
Union Territories
Chandigarh Andaman & Nicobar Islands Dadra & Nagar Haveli Daman and Diu Lakshadweep
Note: Follow Instructions. See Help for Codes in the Annexure given along with this Unified Form for New LL/DL