Duplicate

Please read booklet INF1D before filling in this form.

Please use CAPITAL LETTERS and fill in this form in BLACK ink.

1 What are you applying for ?

Please put x against all that apply :
A first provisional (learner) licence (with a view to passing a test) x
To drive a car at 16 because I am getting Disability Living Allowance (mobility component) at the
higher rate
To replace my licence as it has been :
lost x stolen x defaced x destroyed x
To exchange my paper licence for a photocard licence x
To renew my licence at age 70 or over x
To renew my licence with a new photo x
To change my address on my licence x
To change my name on my licence x
To renew my licence :
For medical reasons x
Because it was revoked x
Because it was disqualified x
If you were disqualified in the UK please give (if you know it)
the date: D D M M Y Y Y Y
and the name of the court:
To exchange my licence:
After passing a test x
Enter categories passed here
To add provisional motorcycle entitlement x
To remove expired 25kW motorcycle restriction x
To exchange my full Northern Ireland licence x
To exchange my non-UK licence for a GB licence x
Which country issued it ?
In which country did you pass your test?
If you passed your test in Canada, see booklet INF1D.
xxxxx
If your licence has been withdrawn, suspended or cancelled in any other country (e.g because of
disqualification), please state which country

2 Your details
Your GB driver number (if you know it):
PRUTE812115V99RY
Title:Mr x Mrs x Miss x Ms x Other (for example,Dr) xxxxxxxxxxx
Surname : Vladislav
First names : Pruteanu
Date of birth :

11121985
Full current address
House No. 6 9 D D D

Somerset Avenue Chessington

Postcode K T 9 1 P S
Full phone/mobile number: 07931265002
Email address : vlad.pruteanu@gmail.com
If any of your personal details above have changed since your last licence was issued please give the
previous details below.
Country you were born in:
If you have lived in another
EU/EEA country in the last
12 months, please tell us which:
What date did you
DDMMYYYY
come to live in the UK ?
To apply for a GB driving licence, you must be normally resident in
the UK for more than 185 days (see booklet INF1D).

3 Your eyesight
Please see note A over the page and refer to INF1D.
Can you meet the legal eyesight standard for driving? Yes x No x
Do you need to wear glasses or corrective lenses to meet this standard? Yes x No x
Organ donation
I want to register my details on the NHS Organ Donor Register to donate the following after my
death. Please put xin the box(es) that apply:
(A) Any of my organs and tissue x or
(B) Kidneys x Corneas x Heart x Lungs x Liver x Pancreas x
Duplicate

4 Your health
Please see note A on opposite page.
Have you ever had, or do you currently suffer from any of the following conditions?
Yes x No x
If you have answered 'Yes', please put x in all the appropriate boxes and send your application to
DVLA, Swansea, SA99 1TU
Diabetes controlled by insulin (no need to notify us if you have diabetes controlled by
1 tablets or other injections unless you experience hypoglycaemia requiring the
assistance of another person)

2 Epilepsy x
3

Any condition affecting both eyes, or the remaining eye if you only have one eye
x
Not including colour blindness or short or long sight

Any condition affecting your visual field or acuity (apart from wearing glasses or corrective
lenses)

5 Total loss of sight in one eye x

6 Stroke with any symptoms lasting longer than one month x
7 Fits or blackouts x

8 Any type of brain surgery, severe head injury involving in-patient treatment, or a brain tumour x
9 An implanted cardiac pacemaker x
10 An implanted cardiac defibrillator (ICD) x
11 Repeated attacks of sudden disabling giddiness x
12

Any other chronic neurological condition including Multiple Sclerosis, Motor Neurone and
Huntington's Disease

13 A serious problem with memory or periods of confusion x

14 Persistent alcohol misuse or dependence x
15 Persistent drug misuse or dependence x
16 Serious psychiatric illness or mental ill health x
17 Parkinson's disease x
18 Narcolepsy x
19 Sleep apnoesa syndrome x
20

Any persisting limb problem which needs driving to be restricted to certain types of vehicles or
x
those with adapted controls

21 Severe learning disability x

Have you told us about this condition before? Yes x No x
Has this condition got worse? Yes x No x

5Your proof of idendity

Please see note B on opposite page
Part A - Valid UK passport holders By entering your passport number in the box below, you are giving
DVLA permission to access your details with Her Majesty's Passport Office (HM Passport Office)
Valid UK passport number :
Please do not send in your valid UK passport if you have completed this section.
Part B - Documents enclosed to prove your identity
Please put x against all original documents enclosed.
As birth/adoption certificates are not absolute proof of identity, you must also send one
other form of identification. Please see booklet INF1D.
Passport x UK birth/adoption certificate x EU/EEA identity card x
Evidence of SRP (State Retirement Pension) x Travel document x
Biometric Residence Permit (BRP) x
Please write the serial number(s) of the document(s) you are enclosing:
053376459
Photocopied/laminated documents are not acceptable.

Documents enclosed to verify a change of name

Please put x against the original document(s) you are enclosing. This must show a clear
link to your current name if different from that shown on your digital UK passport or the
identity document(s) that you are enclosing.
Marriage certificate x Civil partnership certificate
x
Divorce certificate x Deed poll or statutory declaration x
Please write the serial number(s) of the document(s) you are enclosing:
053376459
Photocopied/laminated documents are not acceptable.

6Signing a photo to verify idendity (if necessary)

See booklet INF1D and note C on opposite page.

I have known the applicant for years (please state how many, it must be at least
two years within the UK).
I can confirm it is a true likeness.
I have signed the back of the photo.
I agree to you undertaking checks.
Full name :
Business or home address :

Postcode :
Full daytime phone number:
Profession :
Signature:
Date : D D M M Y Y Y Y

Your checklist
Do not send cash.
I enclose:
The correct fee of:
Cheque or postal order number:
Your last licence (if applicable): x

7 Your declaration
I declare that I am resident in the UK and understand that it is a criminal offence to make a false
declaration to get a driving licence and that to do so can lead to prosecution and a maximum
penalty of up to two years imprisonment. I also understand that failing to provide information is an
offence that could lead to prosecution and a fine of up to 1000.
Important Date: D D M M Y Y Y Y
We will not accept this application unless you sign below in black ink and your signature
is completely within the white box.