Appointment Schedule

FORM 2
[See Rule 10]

Form Of Application for Learner's License

Date :27/07/2015
Time :14:00 - 15:00
Place :DHAMTARI DTO
Reference ID :CG05220715319061
Your test reference number : 319061

To
The Licensing Authority
DHAMTARI DTO

I here by apply for a license authorizing me to drive as a learner.

The following motor vehicle(s) :
a)
b)
c)

MOTOR CYCLE WITHOUT GEAR(Less Than 50 CC)

MOTOR CYCLE WITH GEAR
LIGHT MOTOR VEHICLE-CAR-NT

1. Full Name of the Applicant

DR ADITYA SINHA

2. Son/Wife/Daughter of

KANHAIYA LAL SINHA

3. Permanent Address
(Proof to be enclose)

S/O K.L SINHA

JODHAPUR,DHAMTARI
CHHATTISGARH,493773

4. Temporary Address/Official
Address if any

S/O K.L SINHA

JODHAPUR,DHAMTARI
CHHATTISGARH,493773

5. Date of Birth
(Proof to be enclose)

29-Apr-1986

6. Educational Qualification

MBBS/BDS

7. Identification Mark(s)

SCAR ON LEFT HAND

8. Blood Group

AB +ve

9. If place of birth outside India, when migrated of India

10. I hold an effective driving license to drive:
a) motor cycle/light motor vehicle/medium passenger
motor/medium goods vehicle with effect from
11.Particulars of any driving license previously held
by applicant,whether it was cancelled and
if so ,for what reason
12.Particulars of any learner's license previously
held by applicant in respect of
the description of vehicle to which the
applicant has applied.
13.Have you been disqualified for holding

Please affix a
photo
of the size
5 cm. X 6 cm.

or obtaining driving license or learner's

license if so for what reason
14.I enclose 3 copies of my recent photograph to be size of 5 cm. X 6 cm.
15.I enclose medical fitness certificate date
Issued by doctor
( For non transport vehicle license bring Self attested medical certificate and for transport vehicle bring medical
certificate form prescribed medical officer.)
16.I have submitted along with my earlier application for learner's license /
I enclose the written consent of parent /guardian (in case applicant being minor).
17.I enclose driving certificate date
name and address of the driving school.

Issued by

18.I have paid the fee of Rs.

19.I am exempted from the medical test under rule 6 of Central motor Vehicle rule 1989.
20.I am exempted from the prelimiary test under rule 11(2) of Central motor Vehicle rule 1989.
Strike out whichever is inapplicable
Date

Signature of applicant

Specimen signatures or thumb-impression of applicant

Declaration under sub section (2) of section 7 of the motor Vehicle Act 1988 Shri / Kumari
Son /Daughter of
who is minor is under my care and i accept responsibility for his/her driving. If at a later date I decide not to accept
responsibility or is/her driving I shall intimate the licensing the authority in writing for the cancellation of the license
I give my consent for his / her obtaining learner's licenses.
Signature
Name and Full address of the
Parent / Guardian
Relationship
(To be signed in the presence of the Licensing Authority or Person authorized in theis behalf by the licensing Authority.)

For Office Use

The applicant exempted from the medical test under rule 6 and prelimiary test under rule 11(2) of the
Central Motor Vehicle rule 1989.
Learner's License may be issued.
* The applicant was tested with reference to rule 11(1) of the Central motor Vehicle
Rules 1989. He has passed the test Learner's License may be issued.
* He has failed in the test.Reason Should be specified.
* Learner's License may be refused.
Strike out whichever is inapplicable

Remark :

Signature of Licensing Authority or

Other person authorized in this behalf

The candidate has to either carry original documents or submit certified copies at the time of
documents verification.